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.
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.”
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.
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.
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.”