A digital health future: The risks and opportunities
Dr Ayman Shenouda
An uncertain future
Technology will never replace doctors. That part is clear (or to me at least).
But there’s still a lot of uncertainty ahead and we’re all being told to prepare for significant changes. We’re now seeing daily discussions around the Fourth Industrial Revolution and that it will see unprecedented workforce change.
Despite threats of robot doctors, online lawyers and automated architects, it will be those distinctly human capabilities that will prevail. It is our heart that distinguishes here and no amount of automation can replace it.
At the same time, we will need to be ready for it. Because, if, as predicted, technology sees radically different healthcare systems emerge we need to be ready to embrace this change. Leadership will be required in shaping and refining quality standards to ensure continued best care for our patients.
Change is already here
There are already some significant advances taking place providing a glimpse of what is to come. Much of what we are seeing now is user-driven as technology uptake in the community increases such as through iPhone health monitoring apps.
There is certain strength in technology in empowering patients to take responsibility for their own health. Many aim to support self-management outcomes through patient empowerment, but it is clear that a lack of evidence-base undermines quality and safety in some.
There is discussion around how certain free medical apps are placing patients at risk through false or misleading claims. From instant blood pressure apps giving falsely normal values to apps that claim to measure blood pressure, oxygenation, and more – all without any peripherals.
Health apps present significant challenges to regulatory authorities. And I’m sure it’s not easy for developers to navigate the regulatory pathways either.
In Australia, we have TGA guidelines for what software constitutes a medical device. But how much monitoring is being undertaken to identify non-compliance, particularly around claims on these apps, is unclear.
The next phase of change
It’s clear a soulless search engine or app device is a long way from replacing a GP.
But what about the next phase of change? Deep learning breakthroughs of machine learning and artificial intelligence and precision medicine are likely to influence the way we provide care.
Big data analytics involve descriptive analytics, predictive analytics, and prescriptive analytics. It is the latter, in prescriptive analytics, which leverages descriptive reports and predictive data to identify actions that would produce maximum value to help us develop and adhere to optimal clinical pathways.
Clinical decision support (CDS) on the other hand is set to enhance health and healthcare teams. It will provide both healthcare teams and individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow.
If the future of medicine is based on data and analytics in guiding decision making, then most critical to success will be that the GP remains in control of the clinical decision-making.
To safeguard patients, address questions of liability, and foster trust we need transparency in terms of how clinical decision support tools derive their results. Developers and vendors of clinical decision support tools must be transparent about their methodologies, capabilities, data sources, and limitations.
CDS in developing treatment plans will require leadership from the profession in terms of how we can integrate these systems successfully into our practices. In testing the efficacy of these emerging technology in improving the care and treatment of patients there will be a need for strong consistent discipline specific input.
For Australian general practice, there is a role for our College in joining multidisciplinary technology assessment committees. Currently, the RACGP Expert Committee – eHealth and Practice Systems lead much of this work.
The RACGP Technology Survey released earlier this month will help to gain more insight into the current trends in technology adoption in general practice. It will be interesting to see these results (which closed 3 December) particularly the views of technology use to improve collection of patient data and for clinical decision making.
Benefits in service improvements
Emergent technologies which present new opportunities for healthcare service provision provide great promise. These are technologies that interface with patients in maintaining health, receiving care, and managing a condition.
These new types of technologies – wearables, ingestibles, and embeddables – will be transformative.
Management in the home for the elderly and frail will benefit significantly from new technical innovations. Just by adding in a number of sensors to the body to monitor we will support older Australian’s independence as well as take some pressures off the service system while keeping them safe.
Reliance on these systems would need to be balanced or potentially worsen social isolation and loneliness which are already significant health risks for the elderly. The value of human contact and continued doctor-patient and nurse-patient relationships are vital here.
The next phase of wearable technologies will see patients constantly monitored remotely through wearable skins sensors or smartphone apps with data uploaded directly to their health record. These technologies aim to support the management of chronic diseases, such as diabetes and heart disease.
The advent of the digital health coach (Next IT) to remind patients to take medications, schedule doctor appointments represent a new type of technology to support medication adherence.
The UK is leading the wearable technology space with pilots underway which will see patients’ issues with state of the art wearable technology.
These initiatives are designed to take pressure off the system but also to monitor conditions more effectively for a diverse patient cohort. Some pilots will enable independence for the aged through home monitoring systems with others supporting mental health patients stay in touch with support networks.
It is predicted that, as part of a widespread digital revolution of healthcare in Britain, within 5 years patients across the country will go online to speak to their GP via video link, order prescriptions or see their entire health record.
For implementation in Australia, a final note on the digital divide is warranted. Equity remains an issue despite the promises of high patient engagement through new technologies.
So much of the discussion around technology as an access enabler really misses this point. What about those millions of Australian households living without an internet connection?
Telehealth implementation has been patchy in rural Australia due to the lack of fast and reliable internet, despite the (slow) rollout of NBN. Assuming we all get access by the time these technologies are fully realised, not all Australians can afford access to the internet or the digital resources required to drive new innovations.
For equitable access, we would need to see policies that can provide unmetered online access for the disadvantaged. A commitment to extend the Health Care Card to address the digital divide should be in the planning if we are to strive for equitable access outcomes.
Leading the discussion
Healthcare’s technology revolution is likely to see significant change. Doctors have been described as late adopters of technology in the past. It will be important to be ready and even more important to be part of the discussion. That is, the one that is occurring now!
Finding new ways to connect patients to our practice is positive and possible right now. Future broader technology enabled supports to integrate services and strengthen monitoring of patients can see a positive new change which can only enrich patient care. We’re on the cusp of enormous change and our combined leadership is required in balancing risk with opportunity. Let’s all take up the challenge.
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Dr Ayman Shenouda