The headlines across the globe tell a story of transformation, reform and renewal within the healthcare sector.
We are constantly being advised that traditional healthcare is being reimagined.
Many of the patients currently attending hospitals, will, we are told, never need to attend in the future, as AI powered predictive care will prevent many of the health issues that normally fill our hospitals.
Digital records on the Social Determinants of Health (SDOH) such as inherited medical conditions, what we eat, where we work and whether we have access to stable and clean living conditions will allow us anticipate whether we are risk and take preventative measures at a very early stage and thereby avoid being hospitalised.
As hospitals are given the "digital equivalent of brains and a nervous system"1 such as smart sensors, artificial intelligence, robotics and automation, technology will now facilitate immediate patient scanning, assessment and treatment delivery, which will transition seamlessly from the "Hospo-Tech" to the home.
Hospital and homecare will be connected to a single digital infrastructure tracking vulnerable patients earlier and deploying healthcare professionals and patients to where they can best serve and be served across multiple locations.
"The glue that binds this network together is no longer location..... it is the experiences of the people it serves."2
This view that it is the people and not just the technology that are key to unlocking the heralded transformation in healthcare delivery is worth exploring further. It is important that we interrogate and understand the real drivers of transformation so that we can be certain that the changes we are beginning to see are fully enabled to deliver the patient empowered, patient centric, community wide care delivery system we so desperately need.
While this headline worthy vision of transformation in healthcare may seem whimsical and wishful thinking to many, in fact, the vision for this type of connected care system has been considered and promoted for the last decade.
In Ireland, Sláintecare (the 10-year program to transform our health system) was first considered in 2016 when the future of healthcare committee was established by the Dáil (after much debate on the need for reform). The objective of Sláintecare is to keep people well at home for as long as possible and provide timely access to hospital services when necessary.
The technology has also been available for some time. The MedTech sector in Ireland generates circa €12 bn in exports annually and employs 32,000 people in Ireland. The global telemedicine market size was estimated at USD $41.4 bn in 2019.
Arguably, the transformation hitting the headlines now is not as a result of any new vison or new technology alone, but more interestingly is a result of a transformative shift in mindset.
Historically, there has been a real reluctance to adopt new technologies in healthcare. The contrast to the rates of adoption in communications or retail is stark. Patients have been slow to opt for innovation over traditional person-to-person care. Doctors worry about technology failures caused by outages or simple human input error. Going digital creates extra work, familiarizing oneself with new technology in an overstretched care environment with systems that work "well enough". Within the existing infrastructure, investment in digital is rarely a priority. Hospital administrators are reluctant to spend tight budgets on cutting edge technology, if neither patient nor physician are likely to change their behavior and adopt it.
The Corona Virus pandemic has been a gamechanger, compelling both patient and physician to use technology advances to facilitate their treatment. It is this culture shift that will accelerate the role of technology in health care. Increased adoption will drive further investment and encourage innovation.3
In the UK, Dr. Doctor's video consultation portal solution and Intouch's integrated virtual clinics management platform, which were scheduled for release in late 2020, accelerated their development and launched earlier this year to alleviate pressure on NHS hospitals as they struggled to cope with managing and treating patients during the pandemic. By connecting the portal to the platform, patients can now manage their appointments, launch video consultations, complete digital assessment forms and check in for their in-person appointment all from home. The potential for this technology is only just being explored, prompting the CEO of Guys and St. Thomas, NHS Trust to encourage colleagues to "come and see the system live and consider what it can do in your practice".4
While this digital shift is to be encouraged for the efficiencies and personalised care it enables, if, as we suggest, it is being driven by people as much as technology, then it is vital that it is managed and regulated in a way which builds patient and physician trust while avoiding unnecessary dampeners on innovation.
Paul Reid Director General of the HSE commented in a Business Post article Sunday August 9 2020 that Covid 19 has fast tracked reforms in the Irish health system that may have taken years to happen otherwise.
Paul Reid is eager, he said, to run with this momentum and recognise the new world we are living in, focusing on actions, targeted to give a bigger impact: "Anything that involved tele-health and community services needs to be accelerated" along with "the development of community-based healthcare".
Technology is at the core of these objectives. However, the development and roll out of these technologies is not straightforward. There are many twists and turns ahead before we successfully reimagine healthcare delivery.
The real catalysts may be the shift in mindset, the culture change, the desire and state of readiness to be part of a system exploring new ways of doing more with less in a patient centric way. That perhaps is the real transformation coming from the pandemic and not the technology itself.
If this is indeed the case (and there is evidence to suggest it is), then Paul Reid should focus first on the people at the centre of this "new world"; the patient, the physician, the innovator. He should ask them what it will take to ensure they feel secure enough to swop face-to-face for screen-to-screen consultation and treatment; what will enable them to trust the AI delivered analytics; and what will incentivise them to innovate for a better healthcare system.
A 2019 digital risk report and white paper RSA Digital Risk in Healthcare Today 2019 identified the major risks emerging from digital transformation in the healthcare sector.
These risks include:
In the US in 2019 healthcare was one of the top two industries most targeted by cyber threats5 As wearables, apps, sensors, robotics, monitors and implants make up the internet of medical things and as they are deployed to a myriad of users across many different platforms, they are very vulnerable to cyber-attack. Cyber security threats remain the biggest drawback to increased digitalisation in healthcare. Investment in robust data security systems and blockchain technologies will be as important a driver of digital health as wearable devices and mobile monitors.
In the two years between 2016 and 2018, healthcare data grew 878% and it was expected (pre pandemic) that by the end of this year at least 25% of all healthcare data will be collected by the patient themselves. While GDPR sets the ground rules for regulating data privacy and in particular special category data such as healthcare data, risk management practices must keep pace with digital transformation efforts. As healthcare workers provide care from multiple locations, they require secure and rapid access to information by mobile and web based applications and in so doing risk exposing healthcare organisations to improper use and access.
AI and Data Analytics
Quality machine learning requires quality data. Biased data can lead to biased models and algorithms that function differently in different populations. Given the breadth of machine learning uses across healthcare, the breadth of techniques in use and the breadth of data and human involvement, the requirement for any given machine-learning algorithm depends heavily on the context. Opacity in machine learning may impair our ability to assess medical devices safety and effectiveness. Where machine learning constantly retrains using incremental learning from streaming data, we need to be able to assess the safety and effectiveness of these models in real time.
While AI is not explicitly mentioned in the GDPR, many of its provisions are relevant to the use of AI. However, there are tensions emerging between traditional data protection principles such as purpose limitation and data minimization and the full deployment of the powers of AI. In addition, a number of AI related data protection issues are not addressed in the GDPR. Controllers and processors are calling for additional guidance. The Scientific Foresight Unit (European Parliament June 2020) has called for a broad social, political and legal debate on what standards should apply to processing of personal data using AI. The debate, it is felt, should also address what applications should be barred and which may be admitted under specific circumstances and controls.
If building momentum around the acceleration of digital health technologies is the goal the government, the HSE and the private sector must focus on the management, mitigation and regulation of risk areas so as to build trust across the human network as much as the enablement of the technology itself.
If the transformation in healthcare has in fact been accelerated not just by technology but by people and their willingness to adapt and adopt, the continuation of this transformation toward a future vision of "being consumer centric, efficient and based on high quality data and accessible technology" depends on our ability to build and maintain trust in the new healthcare infrastructure. Big Tech has shown us too many examples of what can happen when trust is an afterthought, a nice to have when everything else is in place, for us to let it happen in healthcare when it is truly a matter of life or death.
1. Michael Rodgers futurist health management.org Volume 20 issue 1 2020
2. World Economic Forum 7 January 2020, Carla Kriwetceo Connected Care and Health Informatics.
3. Year over year, Q2 2020 saw a surge of over 22% in VC investment in life sciences with a quarterly high of USD $7.8bn.
4. Medtechnews.com 4 June 2020
5. Statista - 5 August 2019.
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