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Welcome everyone to our breakout session about digital transformation to this very exciting uh conference again this year. Um We have a line of great speakers from what I can see and very exciting projects to hear about. Uh My name is Theo FTEs. I'm gonna be sharing this session and uh along with me, I have the pleasure to have Bella Thompson and John Alvarez, our postgraduate researchers. And with no further ado, I would like to invite uh Jill Moore uh who is coming from Somerset from the from medical practice to talk to us about successfully supporting patients to switch to dry powder inhalers, opt out text message case study. So Jill uh ba to you, thank you, Theo. Good afternoon, everyone. I hope you've all had a good lunch break. We know what a notorious session, the post lunch uh one is so hopefully you're not all too tired. As Theo mentioned, my name is Jill Moore. I'm a clinical pharmacist and I work at from medical practice uh which as you mentioned is in Somerset in uh sort of southern England. Although it has to be said, I do actually work remotely from sunny Wales Uh So setting up this afternoon, it was a slightly stressful, but hopefully you, you can see everything what's going on. So, rather than giving a huge assortment of slides, I thought our little poster has all the information on that we need to discuss. So I'm gonna talk you through the processes, what's happened to sort of to date really. Um And it was looking at smart ways in which to get patients to engage with dry powder inhalers. Uh We, we started this project back in December 22. So we were then obviously coming up from the various lockdowns post pandemic, probably like most GP practices. We had a huge backlog of asthma reviews that needed to be done and each asthma appointment is 20 minutes, there wasn't the capacity to get patients in for their reviews, let alone have discussions with them about changing their inhaler types. So hence the smart way of using the digital services that were available that we started to use during the lockdowns to engage with patients when we couldn't see them face to face. And in our case, it was mainly using AQ Rx. So first of all, we identified a cohort of patients who we thought we could approach through AQ Rx messages to engage them into change into a dry powder inhaler. So the criteria for for these patients is we we needed them to be on a single component, uh inhaled corticosteroid, uh aerosol inhaler or MDI inhaler as as you know, um that that hadn't previously tried a dry powder inhaler and also had never had a recorded discussion about changing to a dry powder inhaler. So we created an email search for this and we identified 82 potential patients that could fit this criteria. Obviously, we also needed patients to have a mobile phone and have consent to be messaged from the surgery via AQ Rx. Also because we were going to be sending resources such as the nice patient decision aid to patients. We need to make sure patients had smartphones because then they could use the links to open up the attachments. There was a little hit and miss. So initially, we thought, ok, well, we initially have an upper age group of 70 hope that most people that receive it, the messages will get in contact with us if they don't have a smart phone and cannot open up that attachment. So the objective as I was mentioning earlier is try to engage patients, make them aware of the environmental impact of meter dose or aerosol inhalers and also to improve asthma outcomes by trying to get people to adhere to a regime that they could use and fitted their lifestyle. So we used a series of AQ Rx messages. Uh As I mentioned, we need to be able to reach a wider audience than we can through face to face messages. We also wanted to educate patients on how to manage their asthma. The importance of using regular steroids to keep the inflammation down in their airways and also encourage the safe disposal of meter dose inhalers. Because we know that when those inhalers are empty, there's actually still a supply of gasses within them that if they are thrown onto the rubbish heaps, they're going to release those gasses. So actually, MDI inhalers need to go back to pharmacies for a safe incineration to reduce that environmental impact on their destruction. So the 82 patients that we identified, we sent an ARX message to and the word of that was you're currently being prescribed X XX uh aerosol inhaler as a practice, we value sustainability. Therefore, we would like to change your inhaler to A H fa free carbon neutral one. We chose the inhalers and please see the touch document for information. So it came with a link to the nice patient decision aid. Now, if anyone looks at that, that's got chat inverse on inhalers, how to use inhalers and also the environmental impact of aerosol inhalers. Within that message, there was an option for patients to to reply back. So it had a if you'd prefer not to change inhaler, please reply to this text or if you would like further information. So we knew then that patients who felt strongly about changing inhaler types or wanted further information could get directly in touch with the team that was behind sending these messages out it also then gave consent to change their medication. So it was sort of implied consent. If they didn't refuse to change, then we had implied consent that they were happy to change. So after seven days, uh when that Rx link had expired, if patients had hadn't replied back to us, we then reviewed them and we updated their repeat medication to a dry powder inhaler. At that point, they were also sent a training video on how to use the dry powder inhaler. Um And we gave them the information that your inhaler has now been updated to a dry powder inhaler. Again. Within that message, we reinforce the link to the training and also a link to say your pharmacist can show you how to use this inhaler. So at least if we weren't seeing them face to face, they would still be engaging with a healthcare professional. And we included that link again about make sure that you return any MDI back to your pharmacy for safe refusal. Again, patients had an option to respond. So had they missed the first message and suddenly received a second message, they could then reply back to us and say hang about, I'm not ready to do this or I'd like a little bit more information. So we, we did this piece of work. So 82 patients initially were involved and we reviewed it after a 12 month period. Uh So the the initial cohort there were only two patients that actually refused to change to a a dry poder inhaler um of the remaining uh patients after 12 months, 85% of them remained on a dry powder inhaler, which kind of suggests that this was quite a successful outcome in approaching patients of the patients that changed back to an MD. This happened in an asthma review. So some of the reasons given were maybe short of breath, which could be the inhaler, it could be a change to their asthma control. Some people didn't like the dry powder left on the tongue feeling. So, you know, actually that's maybe things that we should have thought about and educating and following up a little bit afterwards. Now the obviously the objective was change into a dry powder inhaler to have a much better environmentally friendly device. But when we were reviewing this cohort of patients, we actually also discovered that prescribing of short acting Betagon. So our salbutamol prescribing in this cohort had actually decreased by 35% which again suggests that their asthma control had been improved by using a dry powder. So we had the, the, the the the double win of having put patients on dry powder inhalers and also overall reducing the total volume of inhalers, we were prescribing by the reduction in M dis. So reflecting on this work, um I think we all agree that by changing to a dry powder inhaler patients became less reliant on their reliever inhalers through the reduction in the SAB a prescribing, suggesting that asthma control oil for these patients was improved probably could be because DPS are easier to use. You don't need the patient coordination and there's much less waste with a dry powder inhaler. They have the little counters on the side. So you can see how many doses are left. Whereas with an aerosol inhaler, you know, once it starts to make less of a noise, which might just be, the propellant has reduced. Um then people tend to bin it or start a new one. You know, from the fact that 85% of patients stayed on a dry powder. Most patients are happy to use that and are happy to continue using that. We could have improved again through these of AQ Rx messages, sending a delayed message to patients after they've been on the new inhaler for eight weeks to see if they had any issues. So rather than them going to an asthma review and reverting back to their original inhaler, actually, we should have done that as a, you know, a little bit of hand holding along the way. So certainly it's something we would be beneficial. Unfortunately, we couldn't assess how many more inhalers were returned to. Pharmacies. Pharmacies weren't happy to segregate and count aerosol inhalers in amongst all the other waste that comes back and just finally to kind of wrap it up just so this this quite process through a crx messages. We managed to reduce our kind of CO2 by 2780 kg. I've been informed which is about 7.5 1000 kilometers driving in a medium size car and that's fine. Thank you. Thank you very much Jill for sharing with us this innovative initiative. And uh we will have time for the questions at the end. I know that Bell and Joanna are holding the chat with the questions. So, uh and I know that we have been joined by all the rest of our speakers now. So if I may go back to our first speaker and have the pleasure to introduce Mal Zaman Chima all the way from Islamabad, from the FAA Medical College. And uh they're going to talk to us about fostering digital health in Pakistan, about telemedicine awareness of patients in diverse healthcare settings in Islamabad. So, you know, uh the stage is yours. Thank you so much. Um Can you guys here and see me? Yes, clearly, both. Thank you. Thank you. I'll be presenting now. All right. So um Hi, I'm Manal Daman. I'm a final year medical student from Islamabad, Pakistan. And uh the topic of my presentation today is fostering digital health in Pakistan, telemedicine awareness among patients in diverse healthcare settings in Islamabad. So um ever since COVID-19, I think uh the utilization of digital health has become increasingly popular. Um not only has it made uh the uh accessibility of patients towards healthcare services, uh more accessible, but it it has also reduced the burden on our tertiary care hospitals um especially here in Pakistan. So what is digital health and telemedicine? Um I think for a lot of the population here in Islamabad, Pakistan, a lot of people were not aware of this facility before COVID and even now. So the uh main aim or the objective of doing our research was to make patients more aware a about this, these all of these services. So what do these services include? It can include all of our um health mobile applications, uh electronic health records, anything um ordering medicine, online, having um video consultations with doctors as well as personalized medicine. So it enables our patients to contact qualified doctors in the comfort of their own home. It is time independent and accessible 24 7 and it is also um much um easier on our pockets than to go look for a doctor in person. So studies have clearly shown that is the next step in the development of the art of medicine. So um h how we did the study was it was basically an interventional study. Uh We did it in three parts. Firstly, we made our patients feel a pre awareness questionnaire. Um Then we gave them our awareness interventional awareness session, which was um uh we made a video. It is uh it is basically an Urdu uh national language of Pakistan. So I would just like to show you some of the clips that we used uh in our video. Um I'm not sure if our audience will understand it, but um just to show you guys a quick review of the video telemedicine, a session telecommunication system. Um And so just fast forward a for you. All right. So the video was basically an but um we uh gave them all the knowledge or the awareness about what uh telemedicine was and how they could access it, the different facilities that were available here in Pakistan and Islamabad, all the applications they could use where they could order the medicine, how they can book uh appointments with the doctors, um et cetera. So the rationale of our study was to create general awareness about telemedicine to make it more accessible and obviously to fill in the literature gap regarding the awareness of common man on telemedicine here in Pakistan. So our aim was to raise awareness regarding telemedicine, which would then help to reduce the burden on the hospitals over here, especially since COVID-19. Um protocols of uh COVID protocols were not being followed, people who are getting um hospital acquired infections, um not being uh so um uh the burden on hospitals. So we wanted to uh make the population more aware that you could uh access healthcare services online as well. So our, our objectives were to uh assess the pre awareness knowledge um by making them for a pre awareness uh questionnaire. Then we conducted uh an awareness session about telemedicine. And lastly, we assessed their posta awareness question uh knowledge regard um uh using the same questionnaire. So then uh we determined the effectiveness of our awareness session by comparing both the pre awareness and the post awareness scores. And we also identified the barriers in accessing telemedicine um especially here in Pakistan. Um people have smartphones but um they did not know that the ser these services were available. So um and a lot of people had inhibitions uh about telemedicine, they wanted to go and see the doctor in person and they didn't believe that uh digital uh and applications like these could a actually help them um in accessing healthcare. So there were some barriers but um we identified them and we tried to overcome them. So our hypothesis was to uh create awareness uh that our hypothesis was that the awareness session would have an effect on the knowledge regarding telemedicine. And hypothesis was obviously the opposite of that. Uh awareness of telemedicine was assessment regarding the knowledge, attitude and practice of patients regarding telemedicine. So our uh study was basically an interventional study. We uh did it in seven different hospitals here in Islamabad and we used 98 patients for our um research. And um the inclusion and exclusion criteria are as follows. We used convenience sampling. Um Here are a few of the pictures that um were used basically in our data collection and we approached patients in different hospitals, uh gave them our awareness session, um made them fill questionnaires. And um yes. So we analyzed our data using S PSS and uh T was used to um calculate the uncomparable and boot. Yup. So I'm so sorry. Yeah, so uh about 54% of the people here that we uh interviewed, they had never heard of telemedicine before. And um a lot of people still preferred in person visitations. But um after our awareness session, a la lot of the results changed and I'll discuss the results. So, um these were some of the questions that we uh used in our questionnaires like um so a lot of these were multiple choice as well, like what do you think the limits and services include? Um here were the options and then how, how beneficial do you think online consultation would be? So, uh he, here's like a quick review of all of the questions and the results as well. So our results uh were uh quite positive. Um After we gave them the interventional awareness session, uh A lot of people agreed that it would be beneficial uh than to go looking for a doctor in person. 95% of the people agreed that it was cost effective as well. Um And a lot of people agreed to use this method in the future. Um And, and to access healthcare. So most of our patients still preferred in person visitations as they um felt that online consultation would be a bit of a, a hassle for them or they would not be satisfied uh per se, but um their awareness or their knowledge regarding uh these services increased by a lot. So our study had a pretty positive impact. I would say uh here are our scores. So the P value is less than 0.01 which was, which showed that our results were extremely significant. So 69% of were agreeing to give the me a try in the future. A about 90 96% were agreeing to give it, give it a try in the future. And um yeah, so these are some graphs and charts. So this is the first study uh that provides an insight of the awareness of telemedicine in Pakistan from the patient's point of view. Um This is also the first interventional study uh of its kind because all the previous studies uh were cross sectional. So results uh show that only 46% the sample population had heard of the term daily medicine, whereas 54% were unaware. So this was in comparison uh to uh 58% in India and 60% in Queensland, 94% of the participants owned a smartphone but only 43% had accessibility. Um This was in comparison to another Indian survey where uh 87% owned a smartphone yet only 53% had accessibility and majority of the people were willing to give this method to try in the future, which was about 95% more than 95%. So, um to conclude, to conclude, our findings suggested that despite some apprehensions, the majority of the participants hold a favorable attitude towards telemedicine and most people had the means to access access it but but were unable to do so due to lack of awareness. So we concluded that there was a need for education and awareness programs and we even gave some recommendations like uh we need more strategies, policies programs in which people should be uh made aware of all these services. So that uh it is easier for them to access health care and it would be easier for the uh easier on the government hospitals as well. It would reduce the burden. So hospitals should also integrate telemedicine into their systems over here. Um uh I I know that's probably a bit different over here than it is um in the West, but uh hopefully we'll be able to catch up soon. Um These are our references and thank you, that's all. Thank you very much, Minal for sharing your project and work for all the way from Islamabad. And thank you for joining us. And uh I have the pleasure to introduce our next speaker. Uh Will Palmer uh also from from medical practice in Somerset and will will talk to us about working in partnership to increase digital inclusion, uh reduced waste and reduce carbon emissions uh in from via the recycling, refurbishing and redistribution of electronic devices. We uh next seven minutes. The stage is yours. Thank you. Great. Thank you the um good afternoon, everyone. Um My name's Will from again through medical practice. I'm a digital coordinator here. I'm gonna talk to you about two things digital inclusion and exclusion and also reducing waste and emissions savings through digital donation and redistribution. Digital exclusion is a major issue in the UK as it is across the world. Um Nearly 9 million people in the UK lack very basic foundation skills needed for our growing digital world where there's nearly 4 million families which are below minimal digital standard and 2.4 million families that simply can't afford even a mobile phone contract. There's two main demographics within these um this area main, the first one is between 1630 35 and this is mainly a affordability issue. I can't afford devices. And the second group is 6570 upwards. And this is um an area for lack of knowledge um or motivation. We've been on the front line of free medical practice for the last four years trying to alleviate some of these issues and these fears and we work closely with a number of local partners. We call local partners. These would include the town council, food banks, job centers, police libraries and other community groups. Uh We also work with um three charities and ci CS across the country. The Good Things Foundation, which is a, a national charity and leading um in this area of Digital Exclusion Spark Somerset is a charity supporting charities and donate. It is ACI C for whom I'm a volunteer and I'll talk about that more. Later. We have a number of digital access points within room to help people. Um About three years ago, I set up a digital cafe and a local cafe which is a community space where people can drop in free of charge and just come along and ask questions that. How do I, how do I answer the phone? How do I send an email? How do I attach a document? Um Anything really? Um And we, we, we've held, we've held 100 and 27 2 hour free sessions, drop in sessions and over 560 people. We also have 1 to 1 support in the community in the town. Uh We will go to people's homes or a convenience space and help them with their online forms. Um Government forms making an appointment, a medical appointment, um ordering prescriptions, online shopping, search anything like that. And we supported over 100 700 people. We also given away devices and data free device, uh new devices and cases and some refurbished. Um 250 of those and 100 and 50 free SIM cards, which gives uh six months to 12 months free data, free calls, um, et cetera. Um So we've recently set up something called digital health desks, um, which uh within the medical center twice a week, we support um, people to get on the NHS app and how to make online appointments. And we've in the, in the year or so, we've helped, um, 2540 people and counting in this area, we decided to take this out into the community. Um So we now also have a weekly session, same thing, a digital health desk in supermarkets, libraries, food banks. And in fact, after this, I'm gonna be going to Sainsbury's to help people get online with the NHS app, Tech Amnesty days. Um This is where local communities and companies can donate their devices, old devices um to be refurbished or um yeah, to be refurbished and then redistributed within the community. Froome has donated um over 1500 devices, over four events and that's nearly a million to um yeah, 1 million tons in weight. Now I want to donate it. Um This is a community interest company which dedicated making a positive impact on our community and environment by addressing both the digital divide and also reducing waste. Our technicians received the donated devices, the old devices through our 47 digital drop off points or the tech amnesties, he or they then refurbish and redistribute the the um the devices to individuals and families in need donate. It has donated over 1260. It's actually I wasn't 1280 as of yesterday devices throughout Somerset and over 100 and 70 in Froome alone, we provide local jobs. We donate tech free of charge to those in need and we contribute to a sustainable global environment. Donate. It is a recycle and reuse organization sustainably disposing of e waste materials are sorted, processed and reintegrated into manufacturing supply chains, reducing the demand for new resources and mitigating environmental impact. As I said, we divert digital devices from landfills. We prevent harmful substances such as lead mercury and cadmium from contaminating soil. And to date, it's been around for about three years. We've diverted 10,000 plus devices from landfill to get that bit more in terms of measurables. Those 10,000 devices of approximately 3000 laptops, 5000 phones and tablets, 2000 desktops, 2000 monitors. And as I said, we just, we've given away free of charge of the refurbished devices, 1260 devices given out to our communities to put that in more context. The the 10,000 devices equates to the equivalent of 2.78 million kg of CO2 emissions. Plus we've reduced conflict materials coming back in or coming into our um into our environment, reducing um old electronic components, we've reduced toxic materials and we've also, uh we've avoided land use. The source for those are two European companies, one in Belgium and one in um Netherlands of that 10,000 devices is approximately 46 tons in weight. So I can give you a bit more context there. That 10, that 46 tons in weight is about 31 or 32 reasonably priced cars. And to give you even more context that 2.7 million kg of CO2 emissions is the equivalent of 1000 flights between London and Sydney. Thank you very much. Thank you very much uh will for presenting uh you know, very exciting uh project working in the community also. And uh I have the pleasure to present our last but not least uh presenter uh Mohammed Sha from DTI Dental Hospital. They're going to share with us their quality improvement project on nurse led telephone retainer review clinics. Mohamed stage, you yours for the next seven minutes. Hello, good afternoon. Uh Thanks for allowing me to present this project today. Um So as you've currently said, theo my project is about uh n telephone retainer review. Uh I'm Mohammed, I'm a second year orthodontic uh trainee at Dundee Dental Hospital. Uh And this is a project that we did um as part of the sustainability team uh to kind of do our bit. So, um I think as you're all aware, climate change has been um a topic uh that's been discussed quite a lot. Uh recently and I've put these pictures up to shower. So the first one on the left is, uh kind of the uh global surface temperature from the 19 fifties and you can see the stark change that's happened. Um, and the heat signature that you can see on the right, uh uh last year, uh 2023. So there's definitely been kind of significant changes. So, uh we all need to do our bit uh uh help reduce this. Um I think most of you are probably aware, but I've, I've kind of put, put this up. Um it kind of uh there's seven main gasses that uh contribute to greenhouse gasses. Er and they all kind of have their different um um uh different scales in uh contributing to these greenhouse gasses uh and greenhouse effect and uh the carbon footprint that they leave. Uh So there's a calculation there at the bottom that shows how exactly to calculate this carbon footprint. Uh And how much each gas kind of contributes towards it in terms of health care uh kind of health services in the UK uh contribute kind of 4 to 5% of the public sector emissions. Um So, you know, reducing uh or playing our bit can, can significantly contribute to reducing these uh these emissions. Um in, in uh England and Scotland, they've already set targets to reduce this quite significantly in hope to uh be zero or net zero by uh 2045 and 2040 some changes have already started. Uh for example, removing anesthetic gasses from supply chains and moving away from single use instruments um as well as waste segregation. So uh this pie chart shows kind of these different uh percentages of uh all the different things that can contribute to uh the carbon emissions. Uh And our project really focused on uh patient travel, which as you can see is quite a significant bit or around 31% of all emissions are due to patients traveling uh to us, to our clinics. So what we used to do here at NHS Tayside is to um review patients by telephone. So, more specifically after orthodontic treatment, we would give uh patients retainers uh which is part of the kind of retention phase at the end to make sure their teeth don't move position. Uh And we, they would go, they would well be on our system for about a year's time with uh regular reviews uh to make sure everything is ok. Um We did start to move to kind of telephone reviews of these to prevent the patients from, from coming in and it saved kind of clinical times, clinical time, chair time and it was kind of more efficient and streamlined for clinicians and um for the patients. Uh but when COVID hit everything kind of s uh stopped uh and we stopped doing that. So what we aimed to do uh in our project was to kind of bring these back in. Uh So we wanted to reduce the department's carbon footprint uh by reintroducing the uh retainer review clinics. Uh and the aims would be to reduce the travel time. Uh Therefore, any emissions caused from patients traveling by a car, uh reduce also unnecessary instruments. Um So that would reduce indirect and direct um emissions uh via reducing kind of transport to get, get the instruments cleaned, um and any waste products as well. Uh And it would also reduce uh the electricity consumption overall uh in surgery. Uh And we might not even need a surgery or charity. It could be done uh kind of in the office with a telephone. So this is the protocol. Uh we can uh it might be a bit small for you to read. But uh basically this shows the pathway of the patient uh from when they remove the braces uh on the final orthodontic appointment to about a year's time when they discharge. So if everything goes to plan, uh the patient didn't really, wouldn't be in the department at all. Uh they would be uh triaged uh in these review clinics uh by telephone and they would only come in if there was uh any issues or if they needed treatment. So if they needed a new set of retainers, that's when it would trigger an appointment for, for us to, for them to come see the clinician. So, um how did we calculate, uh, kind of the carbon emissions? We, uh, the distance, uh, between the patient's home address, uh, and the orthodontic Clinic, uh, and we calculated how many miles they would have, uh, traveled. And the CO2 emissions were calculated on that basis. Um, the, the carbon footprint, uh, of using the surgery, um, was also calculated to see how much we would have saved, uh, by not opening, opening of the surgery for the patient uh to. So we found uh overall we saved uh over 756 miles of travel uh for the patient and emissions. Uh The mean mile travel was about uh just under 19 miles. Uh but that varied from one mile to 100 miles. Um This graph show exactly how much, um, carbon footprint say. So, um, we kind of split it up to see how much, um, it would have saved patients who are traveling by train, uh using a diesel car or petrol car. So, as you can see those using car, which were most cars which were most patients uh managed to save a lot. Uh uh in terms of emissions. Um, and this was um, the uh carbon footprint, uh saved uh by those different modes of transport as well as uh the surgery time. So, um, the surgery emissions of, of running the surgery. So, um, you can see it's almost equivalent to the uh the mode of transportation. So it's quite significant So, in conclusion, we, we uh kind of found out that it's a very effective way of reducing carbon footprint. Um you know, brought it down to almost zero. And there were, there was no kind of negative uh aspects that we found during this uh either uh reports from the patient or as a as a clinic and running the clinic. Uh we didn't find any kind of adverse effects. Um The other bene uh the benefits also were to the patient in terms of cost um because they didn't have to travel in whether that was by train or the transport or um in terms of fueling of the car and uh it reduced both energy in surgery. Uh And uh as I've mentioned previously, instrumentation and also um it should reduce cost to the NHS overall uh in terms of uh paying for clinicians cause. Um you, you don't necessarily need a, you know, consult an orthodontist to do this. It can be one of um the nursing staff uh but also um staff uh um are there to help us run the clinics, uh receptionist and decontamination stuff uh as well as those transport and insurance and things. Um in the future, we aim to kind of hopefully do this again uh and continue these clinics for running and reducing the carbon footprint of. Uh we want to kind of be more specific and uh determine the exact mode of transport that the patient uh so we can get a more a uh estimate uh and hopefully carry forward. Um I know this is very kind of orthodontic related and a very specific example of orthodontics. But hopefully just kind of sparked some ideas like the in your Thank you very much Mohammed. And thank you to all our speakers, which I would like to kindly invite them to join our virtual states by turning on your cameras and give the state then to our participants for questions. I know that Bella and Joanna were monitoring that um Bella, would you like to or Joanna to share some of the questions in the chart? Yeah, there has been um some interesting questions coming up a little bit of discussion in the chat as well. But um I will um I guess read out the questions so everyone can benefit um rather than relying on the chat replies. So first questions were um I think addressed to Jill. Um So um Amy was asking what were previous method, what previous um methods were attempted to communicate this type of option around the inhalers to patients? Um And what type of patients responded? Um because um she highlights the technology is fraught with widening the inverse care law. So previously, we assumed that a face to face asthma review was the best way to engage patients and to give that education to them. However, only when we audited, actually our face to face asthma reviews to see if that discussion had taken place and how many patients had actually been converted to a dry powder inhaler. We we found actually only 12.5% of face to face asthma reviews resulted in a patient change into a dry powder inhaler. So we had to rethink our way of doing things. And obviously, as mentioned, coming up from lockdown, having the availability of AQ Rx and the ability to send patient information directly to them through a link helped us engage with a much larger audience. And in fact, we've kind of taken things on a slightly new level now. So when patients are coming in for a face to face asthma review, uh and if they're on uh uh an aerosol inhaler or especially some of the ones with the higher propellants at the older flutiform type inhalers, we'll actually send the patients a message beforehand saying you're currently prescribed now. So we would like you to consider changing to a dry powder. We send them the nice patient decision aid. We send them a train and video link and but it's kind of evolved into, if you'd like to change to a dry powder inhaler, please discuss it at your appointment next week. So we're kind of in in both digital and face to face personal messages there. And we've actually found by doing that we've increased our conversion rate to dry powder inhalers from 12.5% face to face reviews up to 40%. So it kind of shows that the influence that the digital systems and the digital messages have on our audience. So I mentioned that we kept our audience criteria between 18 and 70 we were dependent on them having a smartphone. And usually the the two patients that refused or declined to change. First time around to a dry powder inhaler were both males under the age of 40 which is quite unusual. However, one of them has now changed to a dry powder inhaler. So maybe not all lost. Um And so then there was a follow up question from somebody else from Miranda who was saying was the reduction in in S ABA prescriptions anticipated. And she was wondering whether any potential health benefits like improved asthma control were communicated in additional to the to the sustainability rationale. So that was a very pleasant surprise. Um We, we were not anticipating any change to the prescribing. The the main rationale was to increase our dry powder prescribing. Um So hence when we reordered it at the 12 month mark, just to add in another level, we also ordered how many sappers patients had received in the 12 months prior to change into the dry poder inhaler. And how many post obviously that kind of reduction implies that patients asthma has been much better controlled because there's less reliant on that short acting beta agonist. Um So very pleasantly surprised before we go to the next question if I may kindly ask Mohammed to, if you may stop sharing your screen. So all the part uh speakers can, you know? Yes, you can pop up on our screens now. Thank you very much. Thank you. Yes, Bella, back to you. Thank you. No problem. So, um the next question is addressed at me now, um and the question is um talking about um the fact that since COVID in the UK, there's been huge aversion to the switch to telemedicine in general that sort of push back against medic. And what can we do to increase trust in these systems and assessed value added versus in person consultations? And I don't know if this is a question that um others might want to weigh in on as well because I think it's probably relevant across the board. Yeah. Yeah, of course. Um So our research basically focused on um the awareness of telemedicine, I would say because a lot of people over here still don't know about these facilities that you could um access your doctor or your healthcare provider uh online or through your phone. So um I think our recommendations for those were to um implement more policies or plans or strategies so that people um uh start using these services more, I think because over here, uh the problem is lack of awareness and lack of knowledge, I think in the UK. Um maybe it, there's like um a different uh people are uh like hesitant to use it, they know about it, but um there might be other problems. So I think even over here people still, um even after they got to know about elements they still preferred in person visitations. Um even after COVID. Uh So, yeah, these are uh the barriers over here. Um uh If anyone else would like to add other problems that are faced uh in the UK um uh regarding telemedicine. Um Yeah, we do. Yeah, I think um II think from my point of view, there is clearly an aversion. Um generalistic being generalized is probably an age, an age issue, an older demographic that's through lack of knowledge. And also I said motivation, they've dealt with that for so many years that so many people think, well, why do I have to do it now? So that is definitely a challenge. Age is age is one of the biggest hurdles and I don't mean to be detrimental in that. It is just a fact. Um whereas the younger generation um seamlessly um adopt these, these new digital platforms, I think with uh our project because uh we were quite lucky because it's kind of uh end of towards the end of treatment. So it worked out quite positive for you, for us. Uh It gave a sense to the patient that you know, the treatment is finish, but we, we're not leaving you, we're gonna call you in. OK. Um And if you need anything with it, kind of uh almost an additional benefit of just reassuring the patient. You know, we're still here if you need us and we will check up on you. It's not the end of the road, just a phone call. Yeah, that's really interesting. I don't know if anyone else wanted to weigh in on it. If not, I will move to the next question. I think there are a couple of questions for, yeah. Uh collectively they were for will I think uh yeah, there was scaling the project, bring your questions to which he um very kindly started the dressing with people um in the chat. But if you don't mind, well, I will ask them um Cloud. So other people who might not be following the chat can also hear the responses. So um the questions, there were two, a couple of questions from Joanna that were about um the challenges that you um that you faced when conducting this project around the digital cafe and how you think this kind of project could scale up. Yeah, I mean the challenge for the digital cafe was simply getting the message across that we were there. We were available, but like many things you can promote it through. Um you can promote it through social media, but that's not our target audience because a lot of them don't, don't go through that. So we had to do it through um traditional methods like newspapers and posters, so paper versions. Um and, and then what happened was it's word of mouth. It just, it began to snowball. So when I first started it, we were getting, you know, no one to maybe 123 people, but now we can be up to 15 people in a session. Um And we have a number of volunteers which help us, which is really great. So it was just getting that message out that we are here and we are helping. And as you saw, there was a lot of access points around the town where we provide that digital support in terms of scalability. Yes, it's very scalable. And I'm doing that across Somerset at the moment in a number of towns. And um it's based around the digital cafe or digital hub, um finding uh volunteers to run those but also engaging with local partners like the medical center, like the town hall, like the police, letting them know that we're here and they can then refer people into um getting that, that supple demographic, whatever age group, great. And um so kind of um sidestepping a little bit. Um Miranda was asking, um do you have a sense of any digital access issue issues that could be mitigated through improvements to user interfaces? Um and the design of the digital system within the NHS. So accepting that this would still leave the issues regarding digital literacy and confidence. How, how long have you got, I mean, that's, that's a, that's a very wide question. Um Yeah, I mean, you know, we're facing a number of challenges to, from people who just don't like everything going online. Um you know, again, particularly certain demographics, there is a real issue to, to get people to um accept online, whether it's online appointments, um or, you know, online um making your appointments online, getting your prescriptions online now. So there is, it's, it's getting that, you know, trying to encourage people to, to access those points. Um And also from our point of view is, um we don't want to leave anyone behind. So we still allow people, you know, people who still can make appointment on the telephone. Um but to help reduce the number of people on the phone where now people are making online appointments and that's a really important thing to do because the more people that make online appointments, freeze up the telephone for people who can't use that digital access point. Um And it's sort of trying to get people to understand that. Um So, yeah, there, there are some uh challenges around that. And so then the final question was about whether the um donate it um was a UK wide organization. Um It's not, we're mainly based around, well, we're only based in Somerset and Dorset and, but there are two that I know of. There's the good things foundation, which is a national charity leading in the digital inclusion space. They do provide data. In fact, that's where we get our data sim cards from which are Vodafone 23 mobile. Um and, and sometimes they, they provide devices, they have set up recently a similar thing to donate it, but it's highly oversubscribed. There's also a wheelchair digit of drive which um clearly from the name works in wheelchair. Um and also bar and a so I think that was the oh, hang on. Um That's something you just, yeah. Um I think these were all the questions from the chart. Theo Excellent. Thank you very much, Bella. And uh and I think that it's time to conclude our session probably I will give you back to your lives 10 minutes. So, and on this note, I would like to thank very much our uh participants, the ones who attended the session. Thank our presenters for sharing with us your exciting, innovative projects that they have a real impact in people's lives and uh on the environment, positive impact. Uh Thank you Bella and Joanna for cos sharing this session and thank you to the organizers for giving us the opportunity to be here. So thank you very much all and have a good rest of the day. Bye everyone. Thanks everyone. Bye. Thank you, everyone.