Digital health is projected to be worth $230bn by 2020. Investments in digital solutions and services skyrocketed during 2017, across the spectrum of telemedicine, wearable technology, mobile applications and remote monitoring sensors, with offerings designed to help healthcare professionals and patients prevent and manage illnesses and health risks, and also to promote well-being. However, this feeding frenzy around digital health has the potential both to enhance the healthcare landscape and confuse the picture.
Today’s healthcare systems remain fragmented and over-burdened, stressed by a combination of expanding demand and resource constraints, and they are frequently physician-centric and disconnected from the holistic needs of patients. On the one hand, digital has the power to connect and integrate disparate services and deliver more intuitive, patient-led experiences. On the other hand, with the huge rise in new technologies, devices and applications, and growing amounts of data, there is the risk that digital innovations will add to the fragmentation if issues of interconnectivity, security and access are not addressed.
For Craig Mills, founder of Frontera Group, commentary is still too focused on digital as a channel rather than as a game-changing enabler in health.
“We’re still discussing how digital can help improve familiar tasks. That’s missing the bigger picture. Why do we think Google is looking to invest almost £2bn into health, and Apple plus Microsoft potentially even more? Knowing that the active patient, engaged in their own health, recovers better and lives longer, they see the potential of mobilising the individual end user (through methods that have digital at their core) to radically improve population management. In the same way Apple created an all-encompassing ecosystem in music and mobile, it is beginning to do the same in healthcare. The conditions are set for the complete reimagination of healthcare as we know it. Companies that embrace this fast and hard will access better outcomes and improve population management.”
Putting patients at the centre of care
The pace of change in digital technology is increasing at an exponential rate, but the question remains whether developments will provide little more than hype for the healthcare industry, or whether they will truly transform care.
According to Alex Butler, co-founder of Foundry³ and leading digital health expert, we are making progress. “Technology gives us an opportunity to humanise and personalise healthcare and do it on a scale that we have never been able to achieve before, to reach people that we have never been able to reach before. What digital health has delivered to date is amazing. The examples are legion: an application which can differentially diagnose lesions on skin with 20-30 times more accuracy than a doctor when it comes to skin cancer, or HealthTap’s Dr AI which uses advanced deep learning algorithms and their vast repository of doctor knowledge and data to diagnose via a live virtual consult and route a patient to specialists and services. These digital technologies will open access to healthcare in the developing and the developed world in ways that could only have been imagined in the past. It’s democratising health on a global scale.”
For Butler, the exciting part of digital health’s potential is the personalisation of health – placing individuals at the centre of their care with the understanding that they know best what their needs are and how to meet them. “The overall focus must and should always be on giving people more power over their own health, with the expectation that self-determining power is more effective at helping people take care of their bodies than being told what to do by larger and more distant institutions.” The only way that this potential can be realised is if people own and control their own data. “There will be a gradual degradation of state-controlled healthcare systems as people expect to be able to manage all of their own information on their phone. They will control how they share the data and manage their own health having AI support systems to connect them with support services. The only way that interoperability will be improved is by people managing their own records and sharing them with people when and how they want to do so. There’s no other way.”
A new role for pharma
With the rise of digital technologies, such as artificial narrow intelligence, robotics, virtual reality/augmented reality, telemedicine, 3D-printing, portable diagnostics, health sensors, wearables and so on, the entire structure of healthcare, as well as the roles of patients and doctors, will fundamentally shift from the current status quo. Patients will no longer rely on a single, local physician, but will be able to access digital platforms when they have a specific medical need. In addition, patients will also be better informed about alternative treatments and will expect a more holistic view not only from their respective physician and insurance company, but also from pharma companies. Butler highlights that there’s a critical support role to be played by pharma. “It’s not even about the technology really, it’s about solving peoples’ problems. There’s often a lot of jargon and hype about technologies – for example, Blockchain – but, at the end of the day, you have to think, how will these technologies help people and improve their experiences? I’ve just finished reading a memoir of Wendy Mitchell who was diagnosed with early onset dementia at 58. When she got her diagnosis she said that the NHS abandoned her. She used technology to take back control over her disease and set reminders for her to take her medication, contact and speak to people, etc. What she wanted was help to manage her condition better and pharma is brilliantly placed for that.”
According to Butler, digital is becoming central to pharma’s strategy and the industry is perfectly positioned to develop evidence-based solutions. “Medicine works best when it is a collaboration. If something is going to be clinically significant, it needs to be built-in collaboration with practicing clinical expertise, clinical academia, patient advocacy and real patient target users. However, what lies behind the majority of challenges in health is modifying behaviour. There is an app called GlycoLeap, created in Singapore that looks at activity, nutrition, weight and glucose control and also connects you with behavioural experts who can support you; there is anecdotal evidence that it can reverse type II diabetes. Pharma is perfectly positioned to provide this high-touch support, solving practical problems that help people with their disease.”
Butler’s advice to pharma is to partner with small health tech companies to find impactful innovation. “Big pharma companies will want to partner with big tech companies such as Google, IBM etc, or a big academic institution like MIT or Harvard. But in reality the real advances are not made in that environment. Small health technology companies can be more innovative. If I came up with my top 100 favourite innovations at present, most would have come from small groups of people in academia and start-ups, just patients trying to solve a problem. Even the biggest disruptors in technology didn’t start out to change the world – they just wanted to solve problems.”
Partnership is key
For Suzanne Clough, chief medical officer, Amalgam, a digital therapeutics company, the shift to value-based care heralds great promise for digital health. “The shift in focus to reimbursement for quality and outcomes has meant that physicians are more open to considering digital health to help facilitate a patient’s engagement in their own healthcare. But there are barriers, such as the lack of interoperability, that have the healthcare system grappling with how to best systemise digital health solutions. Additionally, the widespread adoption of digital health solutions by patients has generated an enormous amount of self-reported patient data that, while valuable, is also proving to be, at times, overwhelming to many providers.”
In December 2016, Amalgam announced a partnership with UCB on a comprehensive behavioural and patient support programme for patients living with psoriasis. BEYOND, a mobile application that provides patients with a trusted source of information, tools and support is designed to help people living with psoriasis to reduce stress and improve resilience while living and dealing with the physical and psychological burden of the disease. “The solution is particularly exciting as it tackles the holistic nature of illness while leveraging the knowledge that social and personal determinants of health are key drivers, or barriers, to improved clinical outcomes. The medical community is slowly coming around to the fact that things like resilience, coping skills, optimism and whether people have the social support, nutrition, etc matter when it comes to improving someone’s health. It’s insane it’s taken this long to realise that if we don’t understand the human behind the patient, we’ll never drive actionable interventions and we’ll never contain costs.”
The solution, which combines tools based in cognitive behavioural theory, mindfulness, optimism and gratitude is firmly grounded in evidence-based research and enters into clinical trials this month. “We went to the medical and behavioural literature to find out what has been shown to help people with psoriasis heal, both psychologically and physicially. We took principles from the positive psychology movement on building optimism and noticed how the practice of gratitude has been shown to build optimism, which improves well-being and overall health. Having more positive emotions means an improvement in inflammatory markers, improvement in sleep and overall stress reduction. The literature on mindfulness and how it can impact the body at a physiological level is incredible. No one can dispute that it’s a powerful tool for stress reduction within the context of chronic disease. There’s so much pharma can bring to the table to get these solutions out there. I think digital health in conjunction with traditional therapeutics could really revolutionise how we deliver healthcare.”
Clough says UCB is a role model for how pharma should approach digital health. “UCB has stuck with it, putting the right team in place to see an end-to-end solution come to fruition – something that pharma doesn’t usually do. In the past 10 years, I’ve seen 11 innovation groups come and go very quickly because the expectations weren’t level-set. With digital health, the R&D path is completely different; the regulatory, content and reimbursement strategy are all very different. The beautiful thing about this partnership with UCB is that UCB got that and built a team around this. It’s truly the first ‘beyond the pill’ product that I’ve seen.”
Barriers to digital uptake
There are considerable barriers to digital health being fully adopted. According to Soeren Mattke, senior scientist and managing director of RAND Health Advisory Services (the consulting practice of RAND Health), we have to start with payment reform as without a clear path to monetisation, investment in R&D and digital health won’t happen. “The first problem is that our payment system reflects the episodic nature of healthcare, ie payment is tied to encounters. For many of these digital technologies that operate outside encounters, you don’t have a mechanism to reimburse the user or the manufacturer and so we have a problem with uptake. The second problem is that these digital health apps tend to generate data but they’re typically not coordinated and integrated with physician offices so that no one will look at the data and respond to them. Physician offices are also centred around the episodic payment model and thus do not have an incentive to use transmitted data.”
He explains that proper uptake of digital health will require a change in the traditional payment system. “As long as payment remains solely tied to acute encounters, it’s going to be really hard for practices and patients and developers to change what they do as there is no way to get paid for what they do. Medicare is now paying for remote monitoring. There are efforts to tie payments in practices more to patient outcomes that will allow a more patient-centric view, but the dominant incentives are still transaction-based.”