Interview with Dr. Amir Hannan

About Dr. Amir Hannan

Dr Amir Hannan is a full time General Practitioner at Haughton Thornley Medical Centres in Hyde and a founding member of the Records Access Collaborative having enabled all his patients to be able to have full access to GP held records via the internet if they wish for over three years. Over 600 patients of his are now accessing their GP records this way. He has helped to develop a practice website, www.htmc.co.uk, which supports patients, clinicians and managers in a world where information and services can be made available for patients and their families.

He is the Information Management &Technology lead for NHS Tameside and Glossop (formerly known as Tameside & Glossop PCT), having recently stepped down as Clinical Governance lead and as a Professional Executive Committee (PEC) member. He is also a member of the local Care Record Development Board supporting patients, clinicians and managers to understand how personal health information can be shared across a health and social care setting and to promote best practice by combining local expertise with national and international experience and knowledge. He has recently become the Primary Care IT lead for NHS North-West (formerly known as North-West Strategic Health Authority) and is a member of the Map of Medicine strategy group, NHS North-West.

He is also the Greater Manchester NHS Clinical Assessment and Treatment Service clinical lead on behalf of Greater Manchester PCTs. Dr Hannan has written and lectured extensively on health informatics matters and his experience to date. He is also a member of the HealthSpace Reference Panel (www.healthspace.nhs.uk) as well as the National Clinical Reference Panel for the Summary Care Record within NHS Connecting for Health (www.connectingforhealth.nhs.uk). He is a member of the Clinical Leaders Network (www.cln.nhs.uk); a member of the Primary Healthcare Specialist Group (www.phcsg.org), a branch of the British Computer Society; and a member of the editorial board of the “Journal of Communication in Healthcare”. He feels most patients should become eMPOWERed in order to support Real-Time Digital Medicine!

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Transcript of interview

Dr. Amir Hannan:  Thanks very much for inviting me.

Dr. M. Al-Ubaydli:  Amir I have given an introduction of how I knew you but you wear a huge number of hats and do work in lots different ways there will be a biography on the website, but give us a bit of background about yourself and how you got into this, in the first place?

Dr. Amir Hannan:  Okay well I, I was born in the UK and I grew up in England, went to Manchester medical school, went off and trained to become a GP and having completed, my training I joined 21, Market Street in Hyde and in October 2000 which was the infamous Ship-man had been there beforehand, and I have been there now for eight years, initially working out of the same practice for about three years and then moving into a purpose built surgery, just a few hundred yards up the road from 21, Market street and subsequently I’ve become the information management and technology lead at Tameside and Glossop PCT and I worked for a while as the clinical governance lead for the PCT as well and I was also a PEC member for the organization, I now serve the Primary Care IT lead for NHS North-West which is known as

00:02:00

North West FHA previously and I am also a member of the Record Access Collaborative which is a group of clinicians and System supplies that are working to enable patients to access their medical records online.  I am also a member of the HealthSpace Reference Panel and the National Clinical Records Panel for the Summary Care Record at the NHS Connecting for Health and so I am a champion for the National program for IT as well as my own solution in the practice which allows patients to access the full GP electronic health record online.  I am a member of the Clinical Leaders Network as well and recently have also become the clinical lead for Greater Manchester NHS accounts and that was all [Inaudible].

Dr. M. Al-Ubaydli:  I also said there’s, a huge number of hats that you wear and all of those have followed the work that you began doing in the practice in giving patient’s access to their records.  So I am just curious how you began all this, did you go to the 21, Market street surgery because you went checking patient access or is it once you joined the surgery it was clear that this was the only thing to do to restore confidence, tell me how that started?

Dr. Amir Hannan:  Well I actually just needed a job basically and just answered the way that the advert was put out it didn’t stay it was on Market Street, it simply said that there was a practice in cheshire that was needing a few people and I went along and applied for it and when I asked where do I need to send the CV it was only then that I got the address and then realized that it was place that Shipman had been at, and the goal before I started I was first watching television, I was watching TBT 24 news and there was a sit down protest

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at 21, Market Street that the patients had organized and the press were there recording I all, because o me going in there had been the long term workers that had been working in the surgery and it helped the patients through [Inaudible] times when Shipman had first been arrested and the patients at the time were not happy about this other doctor that was starting at the surgery.  So the day before there was a sit down protest and I was watching it on television thinking that’s the surgery I am going to be walking into and Shipman’s wife actually came in the night before and took the computer system away.  So when I stopped it on day one there was no computer system and there was obviously a sit down protest, the patients were very unhappy about this doctor that was thrust upon them and it was matter of [Inaudible] and I had to work with the patients and the staff to try and regain their trust and start to show them a different way of delivering medicine, which was much more incumbent with the way medicine is done.  Initially it is very hard because patients didn’t trust me they didn’t like the fact that I had been thrust upon them and they, didn’t know who to trust and they had obviously been greatly harmed by Shipman and what he had done and along the way I tried to talk to them listen to them, try and explain to them that all I was doing was the best I could for them, but along the way I began to realize that actually by allowing them to see what was in their record that was a way of, regaining some of that trust, remember Shipman had been writing things in records and he had been claiming that patients had suffered with glyco angina or systemic heart disease

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And in some cases he had retrospectively written into records that they suffered with a condition like heart disease, had written up morphine in their names and then perhaps used that morphine to murder other patients with and so the patients in practice were worried, their names had been used for this purpose and I, realized by allowing patients to see what I was doing record on the screen, which was pointed at them so they could also see what I was recording and that gave them the reassurance and gave them more confidence, back in 2003, I was then approached by researchers from [Inaudible] Institute of Manchester, Institute of science and technology who wanted to look at a way of enabling patients to have copies of the electronic health records that they could then look at and view somehow and so we did this piece of work with 50 patients in our practice and there was another practice and another colleague of mine Dr. Richard Boson [Phonetic] over a Hatfield Medical Center in Glossop and 50 of his patients were also given copies of their electronic records and they were asked to look at that information and see what they made of it. The researcher wanted to know whether it was possible to extract that data which it was and the data would be transferred to a floppy disc or a CD ROM and given to the patient and the research was done, interviewed the patients to try and find out what happened when they saw this information whether useful or not and how they found it helpful.  The results of that study showed that one; it definitely was possible for patients to look at this information and secondly they found it very useful and helpful and so that was back in 2003 and then in 2006 we demonstrated for the first time that

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patients could go along line and access the full GP records online, they wouldn’t have to go into the surgery to get a CD ROM or a floppy disc that goes out of date as soon you’ve produced it they could literarily go online and put passwords in and then be able to access their GP records and since hen we have now got over 600 patients doing this, the numbers are going up, we have not had a single problem in the practice, there have been issues but no single problem in the practice and they are going from strength to strength where the patients are doing it absolutely love it and are very, very pleased about what we are doing and what we are trying to show the rest of the world.

Dr. M. Al-Ubaydli:  That’s great, now you start from a situation where the patients want to look at the records because he mistrust you because as a doctor that had put incorrect and malicious things in the record and that’s a tiny minority of what patients have to be aware of most doctors around the world but then you spread it to actually every single patient, ought to have a good reason for looking their record, its not about the distrust its actually about a partnership that you are describing and I think that you — there’s a leaflet that you have in your practice where you list eight different scenarios for patients, why they might want to look at their records?

Dr. Amir Hannan:  That’s right, we have a leaflet that we give to patients when they come in and its trying to getting them to think about whether access to records might help them and to start with, which of these apply to you and there are eight options that they can tick., Are you a new patient, that has just registered with the practice?  Do you suffer with a serious condition that requires regular check ups with the doctor or no? Have you been in hospital recently, with a serious health problem?  Are you going to the hospital for regular check ups or waiting test results?  Are due to go on holiday soon or do you travel away from home a lot?

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Are you not sure about what’s going on with your health and want to know more?  Have you ever done a search on the Internet whether related to health or not? And, would you like to be able to see your medical records but they do not know how to?  We were asking patients to tick any of those boxes if they apply to you and on the side [Inaudible] if you have ticked any of these boxes, then you should find access to your records?

Dr. M. Al-Ubaydli:  Now what I find unique about you is I think that almost every patient who comes to see you even if they weren’t thinking about medical records and patient records after spending a little bit of time with you and at the same time any patient could have spent with any GP right so it is a normal GP appointment?

Dr. Amir Hannan:  That’s right.

Dr. M. Al-Ubaydli:  They often walk out saying that’s brilliant I really want to look at my record because Dr. Hannan showed me why there might be a reason, and so can you go through each of those scenarios and this is, I want to explain this to a patient and what they can do with that scenario and why it is a good thing to do?

Dr. Amir Hannan:  Well let’s go with the first one.  I’m meeting a patient that has just registered with the practice.  The system that we start, we were the first practice in the world to offer the full access to the full GP record and just so that you are aware I am talking to people from all around the world and I talked to colleagues in America the States for instances who did not have electronic health records and they came back to me and said that we can share the whole record except 17% of it.  So the Americans [Inaudible] of course the obvious question was which 17% is it hat you don’t share with the patient and they came back and said well there’s legislation on certain areas that we are not allowed to share, an example being HIV status and that’s to do with legislation so legislation dictates that 17%

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Of the records cannot be shared.  Well these enabled the full sharing, of the full electronic health record and with no holds bared and so we were the first practice to do it.  We have now got over 40 practices around the country today so we are not unique any more there are a number of other practices that are offering it.  However that’s as compared to eight and half thousand practices in the country.  So most people from public practices that join our practice are not likely to know about access to records, the first obvious one is a new patient that has joined the practice from somewhere else let’s just inform them that you know this is a service that is now available to them, I should add that it’s a complete free service its free for the patients its also free for the practices to offer and so there isn’t any cost attached as such to find the service and the second one; Do you suffer with a serious condition that requires regular check ups with a doctor or nurse?  In the past if you had high blood pressure and may or may not have termed you as that then you have gone away, you have had a blood pressure reading, you may have been given a tablet or not and then years would have gone by without his doing without his doing [Inaudible] until suddenly someone hey look you have had heart stop or a stroke and then notices that the blood pressure is still high and of course in the last few years we’ve now got the quality and are not constrain what the GP’s are now paid by and one of the purposes the [Inaudible] is ensuring the GP’s and practices are paid for the quality of the service that they provide, so we generate a hyper tension register amongst our patients and then we could, how many of our hypertensive patients are well controlled and how many of our hypertensive patients have the, [Inaudible] with that and then you get, you get paid on for that quality service and

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with all these patients instead of being told their blood pressure and then we’ll see you in  a few years time, they are now being regularly advised to come back so that we can check their pressure and ensure its well controlled if its not well controlled and you can instigate new treatments in order to try and improve their blood pressure and so they are coming back to the practice a lot more often, more regularly systematic in an organized manner and those are the sorts of patients who could access their records could actually monitor their blood pressures and see blood pressures that the practices are recording, of course they are also monitoring their own blood pressure a home having bought blood pressure machines or whatever and they can still in their own personal health record and health states as an example of how that’s done www.healthspace.nhs.uk then they could show their blood pressure readings hat they have been recording at home and compare them with the blood pressure readings that we have got in the practice and there could be a discussion about whether they are similar or whether they are dissimilar that’s [Inaudible] management. Have you been in hospital recently with a serious health problem?  That could be a patient who has just had a heart attack and or a patient who’s just had some serious conditions [Inaudible] or a bowel problem of some sort and has been in hospitals very poorly they’ve just been discharged from hospital its very natural in that period of time when they have just come out of hospital, patient might well be very anxious and worried about the future and the situation of what if I suddenly follow again and also I have seen over the last eight years, those patients who do [Inaudible] and turn up at the after hours service or turn up to casualty and find that the doctor they know your name or the doctor at after hours know nothing about them, they’ve not got any information about your health and so

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the patient themselves find it quite frustrating and so again if that sort of access to their records they could show their records to the doctor in the after hours service or in the A&E department and the doctors then have access to all their informations [Inaudible] what medications they are on what [Inaudible] it happens them.  Are you going to the hospital for regular check ups or awaiting test results? This is where a patient may have had abdominal pain I think that they may have had gall stones and I have referred them for an ultrasound scan well usually what would happen is a patient like that would be told book another appointment in three weeks time because hopefully we will have the scan results back by then.  Well my patients who are accessing the medical records, are now able to go online and check rather like they might check the post that comes in the day time and they will go online and check if the test results have come back, if their sound scan does show something they can go back to the surgery and say hey I can see your sound scan now shows gall stones, what do we need to do about it, or is it normal then they might decide to try something else that the doctors advice or they might want to get back and search but at least they know that test results have come back into the practice and what results are.  Again if they book an appointment to see me and they know that they’ve got gall stones and then they suddenly develop abdominal pain again they can turn up to casualty or the after hours they can tell that doctor I’ve got abdominal pain I have my sound scan that shows I’ve got gall stones, I have made an appointment to see my GP I am still waiting to see him but I have got this abdominal pain again and it means that doctor in there is not having to get a whole battery of tests again because they’ve got a better idea of what’s wrong with him.  Are you due to go on holiday soon, or do you travel away from home?  The person who’s going away on holiday, you take your health or ill health with you and if you stay for whilst you are out, whilst you’re way from home you can be a patient who has had a hear stop in the past or you could

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Be someone who is very well and has well controlled asthma then travels abroad suddenly falls ill whilst around there.  Again those doctors, those nurses and that patient that families they now don’t necessarily know what’s been going on in the past [Inaudible] what hasn’t those patients have got access to their records online can go to the doctor in the hospital and in a foreign country and they can go online as if they were, they were home and accessing their records, and I have had patients who have done that and found that save them a huge amount of time and helps the doctor to treat them quicker.  Are you not sure about what’s going on with your health and want to know more?  We are now living in the information age and more and more patients are exposed to it and the public I should say are exposed to messages about their health and well being, there’s a big, big drive around obesity and the fact that more and more people are becoming obese.  Well one of the things that we’ve been doing in general practice, is measuring everyone’s height and weight and body mass index and waist circumference and so on and that’s part of the quality and outcome frame that we have and at the moment that information is taken in the middle of a consultation you are not quite sure why its being taken its put into the computer and it sat in the computer and its not really helping anybody of course if a patient looks at their record and suddenly realizes that two years ago the nurse had checked that their height and weight and measured their body mass index that and now they realize actually I’ve put more weight on and I’m now obese and that gives them information that helps them to start to think about well what do I need to do about it, do I need to go and see my doctor or my nurse, or I need to go and think about joining the Gym you know its coming towards the end of the year now at this time of the year lot of people decide that you know they are thinking about joining a gym again.  Well again if you can look at your body mass index and realize you are obese you might take that into account when you are sitting there

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Thinking about what better Christmas present do I want or what do I want to do in the New Year.  Have you ever done a search on the Internet whether related to health or not?  A lot of my clinical colleagues doctors and nurses think that patients don’t — aren’t really that interested in their health and you know, one can’t imagine them ever actually doing a search on health.  However we know this from few years ago that now there are more searches going on for health conditions than say there is for sex an indication of what the public is doing and of course if they are not doing it, there is a question there that makes you think well why not, why don’t you find out about your health and do a search on. I guess one of the reasons why people don’t do that is they are worried about the information that they might see is it trustworthy or isn’t it?  That sort of makes the question of well why don’t we as GP’s provide patients with trusted websites that they can go to that gives them good quality information and in fact that’s exactly what we have done in our practice it www.htmc.co.uk and if you go on that and if you click on Thornily house medical center or Haughton Vale we’ve got two branches and then click on healthcare we put a whole series of websites there that are trusted websites that patients can go to and can look at the information and if there’s something they are not happy with they can always bring it to up when they come and see us in the surgery and then finally would you like to be able to see your medical records but did not know how to?  It might be that you, you are not particularly worried about your health and you are not particularly worried about finding out what diabetes or heart disease or whatever, but on the other hand you might just want to know well what is in my medical records and you might think with all this information going into IT systems what if there’s a mistake in there, what if there is something in there that’s slipped and by accident through no fault of anybody and suddenly you know the system seem to think that you’ve got asthma when you can have Ebola well how are you

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Going to know the only way you will find out is if you look at your own medical record you will find out what has been recorded about you.

Dr. M. Al-Ubaydli:  So I want to stress again you are going through these with all your patients during the normal time that any GP spends with their patients?

Dr. Amir Hannan:  That’s right.

Dr. M. Al-Ubaydli:  And you are the first practice in the world to have done this to complete 100% access to the medical record?

Dr. Amir Hannan:  The electronic health record I’m sorry.

Dr. M. Al-Ubaydli:  I am sorry the electronic health record.  Now you said that there hasn’t been a single problem in practice though there have been issues could you discuss some of the issues that the patients and the clinicians would have faced?

Dr. Amir Hannan:  Well a number of studies have now been carried both in this country and around the world that shows that up to 30% of medical records have mistakes in them or errors in them I should say rather than mistakes or there are terms that are missing and this is concern so its not at all surprising that when I enable patient to access their medical records they started to identify issues and there might have been mistakes in there and conditions that they didn’t have, there might have been dates that were incorrect so maybe they’ve been diagnosed with breast cancer in 2003 and in the record when actually its in 1998 that they were diagnosed with it. That’s often to do transcription and to do with the way the records are being summarized patients don’t understand that they just think well why this mistake happened. They will be very clear about when their serious condition was diagnosed but you know whatever the reasons are there’s a discrepancy in the date a number of patients have noticed that the day when a child is born clearly as a mothers it is a very, very, very significant event in their life

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The day, their child is born, so when they look at the medical record and find it doesn’t say anything about a full term normal delivery on the date their child was born and they see that as an error, as a mistake and want to correct it.  SO those are the sorts of typical issues that I have come across and its not all the time remember 70% of the records are correct so the majority of the time patients are absolutely happy about it.  Well there have been times when patients who have said there’s an issue Dr. Hannan can you please look into it or potentially correct it if it’s incorrect.

Dr. M. Al-Ubaydli:  So do you find that the time that’s spent by everyone trying to correct these records, do you think that it sort of evens out when you consider the much greater amount of time that would have been spent treating something that was incorrect or not knowing something how do you find that balances?

Dr. Amir Hannan:  The most important thing is trust issue and because the patients who know that their record is correct and they vouch for it and they are happy with are much, much more likely to feel comfortable [Inaudible] in front of the doctor or nurse is looking at their medical record and a patient on the other hand, if they know that the record is incorrect, is going to find that worrying and then you have got the third patient who doesn’t even know that the record maybe right or not right and they apathetic to it and suddenly, if something happens and realized that the information wasn’t there. An example of that might be an allergy you know you might know that you are allergic to Penicillin but do you know whether your medical record says that you are allergic to Penicillin or not and if it doesn’t what are the consequences of that?  The consequences could be that you could turn up to your doctor’s surgery with a chest infection feel very poorly, very hot you’ve not been sleeping very well through the night doctors sees you he diagnoses you with

00:26:00

a chest infection, types into the computer Amoxicillin or Penicillin and the computer doesn’t flash out that the patient is allergic to Penicillin because it hasn’t been told that, the doctor then gives you the antibiotic, you are feeling very poorly you are assuming the doctor knows that you are allergic to Penicillin so why would you question him otherwise you take the antibiotic and suddenly find that you have had an allergic reaction to it and all because the systems didn’t have written on it and the fact that you are allergy to Penicillin.  Now you could argue, well the doctor should have known that that but how would he have known that, I have got 12,000 patients in my practice, how am I going to know whether every little bit of information in there is correct or not I will and you would and if you have got something like that and you take time that you check whether that information is correct or not, if 12,000 people contact the practice and said, they said can you please checked that my allergies on there its going to become very difficult it will become easy on the other hand, if you decide to access your medical records sit down, go through it and just make sure that you are happy that the information there does pertain to you.

Dr. M. Al-Ubaydli:  Now that’s key the change in the attitude that you described very well in your paper towards the partnership of trust and we’ll link to that one on the website its well worth reading, everything you are doing is worth pioneering the UK is GP’s that you are working with in the UK are leading the world on this, you have also had lot of news about the USA, with Google Health, Microsoft Health [Inaudible] and the big hospitals intending adopting these kinds of technologies but yet you, you want this to go much further than the UK and USA, you are actually working on trying to get this to quote “Further afield” can you tell us more about that?

Dr. Amir Hannan:  We would like to [Inaudible] a bit and I think I mentioned the partnership of trust and not really explained what that’s all about.

Dr. M. Al-Ubaydli:  Yeah please do.

Dr. Amir Hannan:  When a patient comes to see me and they might be worried about their health, they might be worried about

00:28:00

something that’s not right within the health isn’t functioning the way or their body is not functioning the way it should and they think they might have health problems, so they’ll coming and see me, what they are doing there is actually expecting me as a doctor to provide them with the best that medicine can offer.  You know do I need to have further tests done, do I need some treatment of some sorts whatever it might be. On the other and let’s take an example, to make, to help us, to help you understand this better.  Let’s suppose the patient’s turned up with back pain, and they have had severe back pain for a few weeks and its gradually getting worse, and its now got to the point where they’ve not slept all night and they have come to see me because the tablets that they are taking are not working for them and they are coming to me expecting me to provide them with the best care that medicine offers to help them with their back pain I am the expert as far as medicine is concerned.  However there is another expert in that room, in the consulting room and that’s the patient.  Now you might ask why is that and the answer is because although I might know what tests to do for back pain, and what medications to provide or what to, work further treatment they might need that patient is an expert on how the back pain has been affecting them and perhaps just as important their families.  So it might be that the husband is coming to see me, it’s the wife that has been up all night because he has not been able to sleep and he has been fidgeting and moving around to try and ease the pain in his back, it might be that the family were planning on going on a walking holiday next year and they are thinking about booking a holiday and they are not sure whether they can or they can’t because of his back pain.  So the patient is an expert on how that particular symptom is affecting him.  Now let’s take things a little bit further.  If the patient can trust the doctor to provide them with the best that medicine can offer

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and the doctor can trust the patient to tell him everything that they want to, about the back problem and the two people come together, the two experts come together so they get a shared understanding of what the problem is and a shared understanding of what the solution is what tests to do, what investigations to carry out, what medication to take, what the next steps thought to be in terms of dealing with the back pain and we develop a partnership of trust between the two of us, that’s the bingo moment but how are we going to get that partnership of trust together and there is one other expert in that, in that consulting room that can help support the verifications [inaudible] and that’s the computer screen why because the computer screen has the patient’s electronic health records that I can look at to see what’s being going on in the past how many other times had back pain what tests they’ve had in the past, what’s worked  for them and what hasn’t but at the same time the patient will also have a personal health record, health space here in the UK, where they can record how they have been feeling where they can record what’s worked for them and what hasn’t what over the counter remedies they have tried perhaps also into complimentary therapy that they have tried to help, to help them with.  So the patient can say [Inaudible], so these are all the things that I have tried in the past that haven’t worked perhaps that being on a website that tells them more about back pain, how its gone to the Map of medicine for instance which is a knowledge base tool that is provided clinicians that patients can access through NHS choices on nhs.uk and they can look at the management of back pain, they can look at where they think they are on that patient pathway and they can look at the different choices.  So the patient says do you think now is the time for us to go get an X-ray done or do you think we should have some

00:32:00

Blood tests done as the Map of Medicine is suggesting because of that fact that I have had this pain for so long and these medications haven’t worked, bring those two together and you get a partnership of trust.  Now it goes further than that because whilst we’ve got in the UK at the moment the electronic health record which we have and the health space which is the personal health record that the patient has and there are other players that are wanting to move into the market and you mentioned two of them Google Health and Microsoft Health [Inaudible] and I can imagine that further down the line there will be products available in the market and perhaps a good pressure machine perhaps a weighing scale and so that when you check the blood pressure or check your weight that information is automatically electronically wified over to your personal health record and that could be individual health or it could be not so helpful so it could be health Space for instance and so this information that you have now got that’s recorded in your own personal health space which you can then share with the commission and that is the potential future that we’re moving towards of course the only thing is that this isn’t just peculiar to the UK and this is something that’s worldwide the Internet is a worldwide phenomenon whether you are in China, whether you are in Somalia whether you are in the States, Canada, Europe, The Far East Australia it really doesn’t matter you could be anywhere in the world and if you’d be able to access the Internet and be able to access information that could help you with the regards to your health that opens a whole new possibility of being able to look after yourself whilst you are abroad but then it also creates certain difficulties for instance if you’ve got diabetes and you’re based in the UK

00:34:00

well I could send you to various websites that tells you more about diabetes and nhs.uk being one of them and diabetes.org.uk being another which is set up by an independent charitable organization but what happens is suddenly you are told, we want you to go off on an assignment and spend three months or six months in Somalia or the States or Australia.  Well then that means you are going to take your diabetes with you and you are not going to have access to me because you are out there for three months or six months and how are you going to get information to help you understand your diabetes?  It’s going to be very, very hard unless you know a doctor over there that can tell you.  Now I think that this is an opportunity a once in a life time opportunity I suppose where perhaps the world health organization might be able to put a structure in place that supports people that are now traveling all over the world so that they could contact the WHO find out what the local resources are that are available to support someone with diabetes, with heart disease, with asthma, chronic [Inaudible] depression all those other things because I treat them with patients who are in Hyde but those very same patients could be traveling around the world and they still need help and advice to support in them there.

Dr. M. Al-Ubaydli:  That’s Great Dr. now the thing I like about you is that you combined very practical things so what patient can do today right now where it’s actually a vision for the long term, what we’re going to do around the world, what are we going to do for different patients in different [Inaudible].  So I wanted to thank you for today’s conversation and thank you very much to come back today.

Dr. Amir Hannan:  Thank you very much for your [Inaudible]

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