Digital health has the potential to transform healthcare systems but this is not news. For several reasons, it’s a promise that is yet to be fulfilled and has kept many of us waiting for this change since the mid-2000s. We strongly believe that its impact can only be delivered through a collaborative, ecosystem approach.
What is digital health and what’s the big deal?
Digital health is a broad subject. So broad, in fact, that at times it leads to confusion and lack of clarity. The subject ranges from wearables (such as Fitbits, the Apple Watch) to diagnostic technologies connected to online databases, telemedicine (and its lesser known sibling telecare), ehealth (electronic health records and in-hospital applications that increase productivity) and mhealth (mobile smart phone apps). Add Big Data to this list and the digital health pot-pouri could mean everything and anything to do with health as long as it is “connected".
As we have seen in other sectors such as online banking and e-commerce, digital health technology has the power to transform the traditional health care sector, which is in dire need of systemic change. Why? The biggest concern is the global economic downturn which has led to a tightening of public health purses. The driver for change, however, was already prominent before the crisis. Our ageing population has and is pressurising both welfare and private healthcare systems. Before the 90s, hospitals were like garages: you could walk in with an issue, get “repaired” and there would be no need to go back until the next “service” was due. Today people live longer, which is a good thing but they are not exactly living longer heather lives. The 75 and over often live with co-morbidities,chronic illnesses, such as arthritis, heart disease and COPD, that need several “services” a month and not just from one specialist or discipline, nor one hospital department or community service. It requires a combination and digital health has the power to bring these diverse disciplines together. The onus, however, is not just on the provider. Digital health also has the power to empower citizens to take care of themselves so that they don’t end up in A&E so often. This is a bottom-up approach based on the fact that prevention (and therefore early investment) is better than cure.
So why haven’t we seen change yet?
Unfortunately, neither approach has worked so far. The top-down approach of implementing digital health has suffered from various setbacks that have led to loss of trust between the providers and citizens. Take the UK’s National Program for IT (NPfIT) which intended to build a digital “spine” across the UK connecting hospitals and sharing information on a grand scale. From the very beginning, it was beset with IT problems (replacing legacy systems) and financial issues, finally resulting in massive scale backs. During this time it went through several IT providers and re-definition of goal posts. The same could be said about other national (and over ambitious) programs such as Obama Care. With so much investment from governments, why was change resistant?
People not technology
If there is one thing the changes in the NHS UK has taught us, its that change comes at the speed of trust. Health is not about technology, it is about people. People here include not just the patient but also the provider workforce. If the workforce is not willing to embrace new technology and adapt it to their traditional knowledge of medicine, change will be piecemeal rather than systemic. In light of this, a more bottom-up approach was prescribed, where the patient (or citizen) was placed at the centre. Everyone knows prevention is better than cure. If we can remain healthy we wouldn’t need to visit the hospital so often. Today, products from FitBit and Apple will tell you exactly how many calories you have burnt, how many steps you’ve taken and whether you have slept well enough.
What does the patient do with all this data if the doctor cannot use it?
There is a wealth of data at our fingertips but existing health systems are not willing or cannot implement this into their recently digitised EHRs. Email exchanges, for example, between patient and doctor are still not widely accepted. Emails with data attachments from wearables is even further away. Even if they were, and the interoperability issues (more on that later) were solved, we would still be left with the big data problem: rubbish in, rubbish out. Modern healthcare is not so modern: medical students are taught first of all, to talk to the patient, not listen. This is changing but students are also taught how to rely on gold standards when taking measurements. A blood pressure monitor is a gold standard, a wrist blood pressure monitor made by iHealth is not (yet). Trackers that measure pulsations and analyse stress may be useful information but not strong enough to make serious decisions until combined with other information around context.
5 approaches to changing the digital health landscape
Ideally what we need is a combination of approaches, or an ecosystem approach. The digital health ecosystem includes everyone that plays a part in a person’s health and care. Bringing them together is the first step but once they are there it is important to take action and not just talk. Here are our recommendations:
- Change comes at the speed of trust. Organisations must first embrace change. Whether its an app for mental health or a new SPECT/CT, if the organisation cannot implement a different workflow, there will be slow or no change. And the change in the digital technology scene is not showing signs of slowing down.
- People not technology. Digital technology is only an enabler not the answer to everything. Here “people” are those that surround a person’s life when they decide to take a decision around health. A person living with dementia needs a diverse workforce (neurologists, psychologists and speech and language therapists to name a few), their informal carers and their family and friends. Each of these actors can use a variety of digital technology to enhance the care they provide. Ideally that technology must be designed and developed with
- Support interoperability. There are several applications, wearables and technologies that can solve problems but they need to be able to take to each other if they expect to make an impact on someones life. Data sharing needs to be supported across departments in hospitals, community services and even volunteering organisations. Data sharing needs to be supported between providers (as a whole) and the citizen. Finally, data sharing needs to be supported between startups, SMEs and large corporations. There is no one size fits all here and therefore we must take a collaborative approach.
- Consider the whole system. This is a much more complex problem. If what we want is sustainable health systems, then we must think of the big picture. The big picture for a 75 year old with chronic illness, includes not just healthcare provision but also social insurance, pension and public transport. Those aspects may not need to be fully part of the transformation program but they certainly need to be aware of the changes taking place and be open to adapting their existing systems.
- Embrace the lean startup way. Past experiences have shown us that we should not build something that no one wants. Governments and providers have mistakenly built the full product well before understanding the customer’s problem. In healthcare, we should learn how to iterate exactly how startups learn by doing in other sectors. Of course, the lean startup needs to be adapted to health systems: we shouldn’t put the patients life at risk trying something. However, startups working in health must be allowed through the door with paper prototypes and policy and change makes must learn to iterate as often as entrepreneurs do.
The virtue of patience is not on the list but it is key to transformation. Change does not happen overnight nor should it be expected to happen in "x years". Investors (not just venture capitalists but everyone with a soft to hard investment in healthcare transformation) expecting immediate ROI should also take a hard look at what ROI means. In health it is much more than financial. Social impact is as, if not more, important. Implementing this into the value of a company or product needs a completely new way of thinking. We believe the best way to think is by doing with others and being part of an ecosystem is the first step.
(originally published on Aug 17, 2016 @ 12:51, on samuhya.com)