Developed Countries

Health Tech

The reality check: Making health tech work in real healthcare settings.

What is it that we like about hos­pi­tals? We have been putting sick peo­ple togeth­er in one build­ing since the days of ancient Greece. And hos­pi­tals were the test­ing grounds for 20th-cen­tu­ry med­ical advances, such as X‑rays, insulin and antibi­otics. But let’s con­sid­er some of the com­pelling argu­ments against them.

Hos­pi­tals can be hard to get to, espe­cial­ly for those most dis­ad­van­taged. And they kill peo­ple. Burnout, which has been found in a sur­vey to affect up to half of all doc­tors in Ger­many, Spain, Por­tu­gal, the UK and US, is a major cause of med­ical errors. Wards and oper­at­ing the­aters are also breed­ing grounds for dead­ly “super­bugs”.

Once a hos­pi­tal has been built, it must be filled with patients to be eco­nom­i­cal­ly viable, even in pub­licly fund­ed health­care sys­tems. So hos­pi­tals pro­vide an incen­tive for unnec­es­sary treat­ment and a dis­in­cen­tive for upstream pre­ven­tive health­care. Despite these facts, hos­pi­tals remain the bedrock of the world’s health­care sys­tems.

Tra­di­tion­al hos­pi­tals were cen­ters for expen­sive machines and hard-to-acquire med­ical spe­cialisms, but the log­ic of today’s fast evolv­ing, data-enabled tech­nolo­gies means that med­i­cine will increas­ing­ly move away from ded­i­cat­ed build­ings and towards patients.

HOSPITAL AT HOME

Niels van Namen, glob­al health­care leader of Swiss-based CEVA Logis­tics, points out that a tsuna­mi of med­ical inno­va­tion has hit the devel­oped world in the last two decades. Cell and gene ther­a­pies sup­port tar­get­ed, pre­ci­sion med­i­cine; drugs are becom­ing smarter. Mean­while, AI has accel­er­at­ed diag­no­sis, and tech­nolo­gies such as drones, vir­tu­al real­i­ty, robot­ics and 3D print­ing are increas­ing­ly being used for med­ical appli­ca­tions.

To these fac­tors should be added the com­mu­ni­ca­tion rev­o­lu­tion of both smart­phones and wear­able sen­sors and med­ica­tion sys­tems, con­nect­ed by the “inter­net of healthy things”. For many peo­ple, van Namen argues, dig­i­tal con­nec­tiv­i­ty could remove the need for human con­tact in health­care. And yet, in the “advanced” med­ical sys­tems of most OECD coun­tries, we still trav­el miles to a hos­pi­tal for a rou­tine test. It makes no sense.

There would still be hos­pi­tals, in van Namen’s ide­al world, but they would be used only for pedi­atrics, inten­sive care, surgery and imag­ing. They would be com­ple­ment­ed by agile, mobile health cen­ters, which would also deliv­er some acute care. For the major­i­ty of peo­ple, includ­ing some with acute con­di­tions, there would be no need to go to the hos­pi­tal any­more – they would receive most of their care in their own homes.

SLOW PACE OF CHANGE

Dri­ven by hos­pi­tal-based invest­ment, the cost of health­care is ris­ing. On aver­age, since 2013, annu­al per capi­ta health spend­ing across the OECD has grown by 2.4 per­cent. In the US it has increased six­fold over the last four decades, from $1,832 per capi­ta in 1970 to $11,172 in 2018.

Van Namen argues that a home-based health­care sys­tem could be up to ten times cheap­er than one deliv­ered from tra­di­tion­al hos­pi­tals with their high fixed costs. The short-term cycles of polit­i­cal deci­sion-mak­ing are the fac­tor that leads, para­dox­i­cal­ly, to inflex­i­ble, long-term invest­ment in hos­pi­tals.

In the future we’ll be ready to deliver more flexible care.

Rachel Dunscombe
CEO, NHS Digital Academy, UK

Admit­ted­ly, some progress has been made. Ger­many has recent­ly passed the world’s first leg­is­la­tion allow­ing doc­tors to pre­scribe health apps. We have pills con­tain­ing microchips and smart­watch­es that can mon­i­tor heart rate to a diag­nos­tic stan­dard using high­ly accu­rate elec­tro­car­dio­gram (ECG) track­ers. But we have a long way to go. The US Food and Drug Admin­is­tra­tion has only recent­ly approved wear­able med­ical devices.

Dr. Greg Parston is a vis­it­ing pro­fes­sor at the Insti­tute of Glob­al Health Inno­va­tion, based at Impe­r­i­al Col­lege, Lon­don. He notes that, before Covid-19, the aver­age imple­men­ta­tion peri­od between an innovation’s arrival and its appli­ca­tion in med­ical set­tings was com­mon­ly cit­ed as 17 years. One prob­lem, he says, is the time required by clin­i­cal tri­als: “It can be argued that they take far too long – we already have the next inno­va­tion before we’ve com­plet­ed the last tri­al.”

ADOPTING INNOVATION FASTER

A study by Parston for the World Inno­va­tion Sum­mit for Health looked at fac­tors which slow down the adop­tion of med­ical inno­va­tion. Its inter­na­tion­al case stud­ies includ­ed pro­grams to pro­mote road safe­ty, vit­a­min use and vac­ci­na­tion and to diag­nose infant HIV; a health insur­ance sys­tem; and the adop­tion of dig­i­tal imag­ing for X‑rays. The main fac­tors slow­ing inno­va­tion, it found, were clin­i­cal bias, delays in the pub­li­ca­tion of research find­ings, and resis­tance to change.

“One issue is that the clin­i­cal lead­er­ship in most insti­tu­tions is old men. If you begin focus­ing on younger clin­i­cians, I think you’ll find a quick­er pace of change,” says Parston. “Also, doc­tors are taught to doubt. That is an impor­tant part of diag­no­sis. And doubt plays a big role in their sus­pi­cion of new ways of work­ing.”

qXR is a chest X-ray screening tool developed by Mumbai start-up Qure.ai. It uses deep learning to automate and speed up the process.QURE.AI

Rachel Dun­scombe is CEO of the Nation­al Health Service’s (NHS) Dig­i­tal Acad­e­my in the UK and a mem­ber of a small group of pro­fes­sion­als advis­ing the UK gov­ern­ment on dig­i­tal tech­nol­o­gy. As Arch Col­lab­o­ra­tive lead for research com­pa­ny KLAS on refin­ing elec­tron­ic health records, she is in a good posi­tion to assess what has slowed down the dig­i­tal health­care rev­o­lu­tion. “It’s not skills. The dig­i­tal pro­fes­sion­als in health­care are in many cas­es where they need to be,” she says.

“In the UK, pro­cure­ment has been a drag fac­tor, but we are start­ing to improve that with new dynam­ic frame­works.” It is also not the tech industry’s lack of will­ing­ness. The main prob­lem, says Dun­scombe, is the lega­cy IT sys­tems that lock in data and can­not talk to each oth­er. “The aver­age orga­ni­za­tion has some­thing like 700 dif­fer­ent sys­tems,” she says. Parston iden­ti­fied four key fac­tors need­ed to speed up change: vision and strat­e­gy, a spe­cif­ic agency to pro­mote dif­fu­sion, ded­i­cat­ed fund­ing, and effec­tive com­mu­ni­ca­tion. When all are in place, the results can be impres­sive.

MORE SMART ROUTING, LESS FACE-TO-FACE

The NHS has invest­ed in tech­nol­o­gy through its high-tech off­shoot, NHSx, its Dig­i­tal Acad­e­my and the NHS Inno­va­tion Accel­er­a­tor. The gov­ern­ment has devot­ed almost $6.5 bil­lion to its dig­i­ti­za­tion strat­e­gy in the last five years. The NHS data-shar­ing plat­form, The Spine, is used dai­ly by half a mil­lion health­care pro­fes­sion­als, sup­port­ing up to 47 mil­lion trans­ac­tions. But this invest­ment is dwarfed in the US where, last year alone, pri­vate investors poured more than $8 bil­lion dol­lars into dig­i­tal health­care start-ups.

Investment in hospitals has driven a rise in the cost of healthcare in OECD countries. In the US, per capita health spending has increased sixfold over the last four decades.

SOURCE: PETERSON KFF HEALTH SYSTEM TRACKER

The hos­pi­tals of the future, pre­dicts Dun­scombe, will be sup­ple­ment­ed by high-tech clin­i­cal back offices that will receive and aggre­gate data from mul­ti­ple sources, enable per­son­al­ized med­i­cine, and deploy human resources as required – whether a nurse, a social work­er or health coach. It has been called an Opo­do mod­el of health­care.

Cen­tral to this vision of inte­grat­ed care are “smart rout­ing tools” and “clin­i­cal field force man­age­ment”. Health­care is ulti­mate­ly about logis­tics – get­ting the right ser­vice to the per­son at the right Invest­ment in hos­pi­tals has dri­ven a rise in the cost of health­care in OECD coun­tries. In the US, per capi­ta health spend­ing has increased six­fold over the last four decades. time, enabled by the right data. The grow­ing num­ber of dig­i­tal­ly enabled patients will rarely require face-to-face con­tact. Those who do need it will get it. How long before this vision arrives? Thir­ty years to ful­ly real­ize, Dun­scombe antic­i­pates.

What about data con­fi­den­tial­i­ty? Con­cern about it has been a major drag on health-tech adop­tion. The need, says Dun­scombe, is for secure, audit­ed, encrypt­ed data that can only be used for the pur­pose of direct care, unless oth­er use is con­sent­ed. The answer? Dis­trib­uted ledger sys­tems, like blockchain. In Esto­nia, 1.3 mil­lion cit­i­zens have the holy grail of a “sin­gle uni­fied iden­ti­fi­er” and a dis­trib­uted record. They can all access their med­ical records online. They also use the sys­tem for vot­ing and shop­ping.

PANDEMIC’S POSITIVE IMPACT

The Covid-19 pan­dem­ic will have a last­ing lega­cy for health­care. In the US, for exam­ple, health­care providers rapid­ly scaled tele­health offer­ings, see­ing 50 to 175 times the num­ber of patients com­pared to pre-Covid. Dun­scombe esti­mates that it has accel­er­at­ed tech­ni­cal evo­lu­tion in some parts of the UK health­care sys­tem by up to a decade.

In some cas­es, tech­nolo­gies pre­vi­ous­ly regard­ed as improb­a­ble ideas have moved straight to imple­men­ta­tion. Dur­ing the lock­down, for exam­ple, it is esti­mat­ed that up to 93 per­cent of GP con­sul­ta­tions were car­ried out vir­tu­al­ly. The NHS in Bolton worked at great speed with Mum­bai-based med­ical tech com­pa­ny Qure.ai to imple­ment an AI-based sys­tem to scan X‑rays for Covid-19 symp­toms. It func­tions thou­sands of times more quick­ly than human eyes.

Oth­er exam­ples include 3D print­ing used to mass-pro­duce screens for per­son­al pro­tec­tive equip­ment (PPE), head-mount­ed cam­eras allow­ing senior sur­geons to super­vise oper­a­tions, and US mil­i­tary robots, used at three NHS sites, to min­i­mize phys­i­cal con­tact with high­ly infec­tious patients.

A robot is used to distribute hand sanitizer at a shopping mall in Bangkok. Mladen Antonov/AFP Via Getty Images

There are an esti­mat­ed 2 mil­lion new med­ical stud­ies a year and med­ical knowl­edge dou­bles every two months. Ideas and inno­va­tions pro­lif­er­ate more quick­ly than any human could pos­si­bly keep up with. But, although human and tech­ni­cal fac­tors may be hold­ing us back, the pan­dem­ic has sig­nif­i­cant­ly accel­er­at­ed both tech­nol­o­gy and its adop­tion. The New York-based Macy Foun­da­tion is set to bring togeth­er aca­d­e­mics and clin­i­cians to learn lessons for med­ical train­ing, as it did after World War Two. And the US Defense Advanced Research Projects Agency (DARPA), begun in the Cold War to accel­er­ate US space and defense tech­nol­o­gy and with a $3.4 bil­lion annu­al bud­get, is research­ing tech­ni­cal and clin­i­cal solu­tions.

“Look at the speed with which we built the Nightin­gale Hos­pi­tal in Lon­don for Covid-19 patients. It was set up in nine days. The pair­ing of mil­i­tary-style gov­er­nance and deci­sion-mak­ing with the best of the NHS and tech­nol­o­gy was incred­i­ble,” says Dun­scombe. “Add to that the abil­i­ty to com­mu­ni­cate dig­i­tal­ly with every cit­i­zen, and in the future we’ll be ready to deliv­er more flex­i­ble care when the next cri­sis hits.”

CALL TO IMPACT
1 To speed up the adoption of innovations, healthcare systems must have a vision and strategy, an agency to promote diffusion, dedicated funding and effective communication. 2 Legacy IT systems that lock in data and cannot talk to each other are one of the biggest obstacles that must be overcome. 3 Covid-19 has shown that technologies that previously had the status of improbable ideas can be moved straight to implementation if the will is there.
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