What We Talk About When We Talk About Digital Healthcare
Several weeks ago, in a post about the broad transformations underway in our healthcare system, I touched on digital healthcare as both part of an evolving patient expectation and changing models of care delivery. I thought it would be helpful to revisit digital health in greater detail to understand the transformation and its implications.
As a preface, digital health advances begin on the “demand side” with what patients want. Some of the trends below reflect patient demands for greater convenience in how they get their healthcare. Non-healthcare businesses have transformed consumer expectations of convenience and customization. Think of how many permutations you can order to have your coffee exactly as you want it at Starbucks. Imagine how a consumer offered those multitude of choices feels when he or she enters the healthcare environment, which traditionally operated under the Henry Ford-esque philosophy that “You can have any color [you want] as long as it’s black.”
From the supply side, digital healthcare reflects the huge leap forward in terms of what is possible based on technology advances. None of the digital healthcare technologies is new, but the increased power of technology is expanding the possibilities, the utilization, and the relevance to the healthcare industry dramatically.
For the sake of clarity, it is useful to begin by identifying several distinct strands of health technology that utilize digital transmission of information and various combinations of telecommunications, hardware, and software, to deliver healthcare services and other healthcare technology solutions. These categories are debatable, as addressed below, insofar as some are embedded within others, and all are closely interrelated. Nonetheless, they offer a helpful construct for describing and understanding the changes underway. What these strands have in common is that, while they are already in use, they also are evolving to a more central role in the next generation of healthcare services. As a consequence, healthcare investors, organizations, and providers should be paying close attention.
While there are different ways to organize the digital health taxonomy, my preference is for the following seven primary categories of solutions, three that are overarching and four that are specific forms. Three strands of digital healthcare that are, in a sense, embedded in every manifestation of digital health technology are:
(1) electronic health records (EHR);
(2) data-crunching; and
(3) artificial intelligence (AI).
Four specific forms of digital health that embed these elements for distinct purposes are:
(6) therapeutic virtual reality (VR); and
(7) health robotics.
Below, I’ve offered some brief thoughts about each of these areas.
- Electronic health records
wElectronic health records (EHR) are the “grandmother” of all other kinds of digital health. EHR represent the earliest use of electronic systems and information technology (IT) solutions to record, store, transmit, and retrieve health data. As a result, without EHR, we would still be in the stone ages of healthcare, lacking systematic data collection and analysis, or ability to measure outcomes. EHR, in other words, is at once a manifestation of digital healthcare and, at the same, the functional foundation on which the digital healthcare universe is built.
EHR took a great leap forward in its utilization in the past decade, thanks in large part to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, through which the federal government paid incentives for the adoption of EHR meeting “meaningful use” standards, deserves credit. The vast majority of physicians and virtually all hospitals have adopted EHR. There are still a few areas of the healthcare landscape where EHR adoption needs to advance (such as in post-acute and assisted living facilities, in general), but progress is ongoing.
Notwithstanding its broad adoption, there are big challenges ahead for EHR. Just a few weeks ago, the acting administrator of the Center for Medicare and Medicaid Services alluded to the end of meaningful use. I am among the observers who take this as a sign that, while the push for broad adoption was successful, the shift to a universally accessible, interoperable system of records, where EHR can follow a patient from one care setting to another, remains a long way off.
- Digital data crunching
Like EHR, the gathering and analysis of health data is both a manifestation of digital health and a foundation for all forms of digital healthcare. My friend Naresh Menon did a nice job a few weeks ago of explaining the role of “big data” in healthcare. We have developed the capacity to amass, organize, and analyze voluminous amounts of health data, including, for example, the information captured about personal habits on smart phones. Thanks to concomitant advances in our ability to process data through powerful computing, we are moving towards a growing body of health analytics that can be used to guide public health and manage “population health” on a broad scale. These same tools also support individual physician decision-making on diagnosis and treatment. As a result, many healthcare problems will be diagnosed and treated more effectively, and the most difficult problems will benefit from “crowdsourcing,” i.e. more efficient problem-solving that leverages everyone everywhere with value to contribute.
- Artificial Intelligence (AI)
The third overarching trend, which is both a modality of digital healthcare and foundational to other forms of digital health is AI — the manner in which digital healthcare devices have gotten and are getting “smarter” and using data for an increasing array of tasks. Think about the next generation of Siri on your iPhone and IBM’s Watson — devices that talk, listen, see, recognize, and ultimately make decisions via pattern recognition and “cognitive” computing. As with data, AI is embedded in all of the above. Telemonitoring devices, for example, will increasingly get better at collecting key data with unprompted visual recognition of the patient and detection of the key data. Robotic devices similarly will perform support functions, such as speech, effortlessly and naturally. AI will enable health providers to have EHR access to your entire medical record and relevant data points at their fingertips. Ultimately, AI represents the holy grail of data-crunching: the point at which our data analysis tools are able to refine and calibrate decision-making.
Telehealth originated with the model of shifting the doctor-patient encounter online by replicating the experience of a face-to-face, in-person visit via telemedicine videoconferencing. This is the area where I have spent most of my time on the digital healthcare landscape, as it has grown steadily as a modality of care delivery over the past decade. Over the past few years, we’ve seen telehealth expand across a wide range of specialties (teledermatology, telepsychiatry, telerehab, and so on). I put together this slide a few weeks ago, reflecting the steadily growing ranks of healthcare provider platforms that allow health professionals to provide patient care remotely utilizing telecommunication and information technology (IT). Telehealth remains the model of many of the leading providers, including Teladoc and American Well, which have been for over a decade, and more recent entrants like Doctor on Demand, which launched in 2013.
That model is evolving. The next generation of telehealth solutions are increasingly streamlined and focused on increasing and improving quality data sources, which will drive changes in the standard of care across a wide range of specialized health services. Already this trend is evident in smart phone apps that target a particular condition or are structured to assess the appropriateness of a particular medication. Our visits to doctors and hospital ERs will be replaced by an expanding array of options to snap photos or input data via our phones and other devices, upload them to a cloud-based software application, and get fast, accurate information about the treatment.
In the process, many minor health problems will be resolved with electronically-delivered prescriptions, which patients can have filled online and delivered without visiting pharmacies. Dermatologists represent the front line of the digital health battlefield because of the ease with which treatment by photos of lesions and skin conditions (what we call “store-and-forward” telehealth) can already supplant the doctor visit. Check out Spruce Health and Direct Dermatology as examples.
Other examples of the expansion of telehealth into hyper-specialized offerings include the 2015 launch of Pacify, an application that offers parents access to nurses, lactation consultants, and dietitians for their baby-related health issues, and icPooch, a pet telehealth service. While these ideas may seem like niche offerings, they are likely to grow in scope and see gradual adoption based on their convenience.
If you are a bricks-and-mortar doctor, hospital, or pharmacy getting concerned as you read this, that’s the point. Healthcare providers need to be paying attention to the ways that patient behavior is transformed by these digital options, which beat the heck out of waiting in the doctor’s office.
Telemonitoring is a related category of technologies that transmit health data, which can be utilized by remote health professionals (and the expanding movement of do-it-yourself (DIY) patients) to monitor and assess health conditions. It includes stand-alone devices, wearable technology, and a host of new tools that detect and transmit health data.
Telemonitoring is already an important force for anyone with chronic conditions. In the same way that smartphone apps described above are making major inroads with a host of minor health issues, telemonitoring is playing a major role for more home-bound patients with chronic conditions such as diabetes and advanced heart disease. The ability to have devices (connected via the Internet of Things (IOT)) transmit data to remote healthcare providers means that patients don’t have to travel to the doctor’s office to check their blood pressure, blood sugar, or other indicators. This, in turn, enables doctors (or increasingly, nurses) to review the collected data, check in with patients and provide clinical feedback via a telehealth encounter, focusing the need for actual in-person visits on home care to provide help with activities of daily living. While many of the current devices require human input to confirm data prior to transmission, the next generation of telemonitoring will detect data with increasing automation.
Perhaps the most powerful role of telemonitoring will be provide early warning signs. Troubling indicators, such as changes in blood pressure resulting from a blockage, can be identified before a heart attack. Doctors can anticipate potential problems and respond before the damage is done, scheduling procedures or directing them to hospitals before a life-threatening event. This process will reduce mortality risks and offer the opportunity for more intensive intervention at home to avoid readmission when preventable. In this respect, telemonitoring will extend the trend underway of suppressing hospital utilization by enabling and encouraging the treatment of increasing levels of acuity in lower-level care settings, with the home being the lowest possible cost care setting.
Telemonitoring tools also extend into the smart phone, such as the growing number of applications that allow patients to manage blood pressure, nutrition, or chronic conditions. In the case of iPhone apps, these applications are offered through the Apple ResearchKit platform or similar health data platforms, enabling the collection and analysis of data from tens (and eventually hundreds) of thousands of users. Researchers will be able to analyze patient behavior and use that information to encourage health-promoting activity.
Another segment of telemonitoring is the growing space for wearable technologies, including the various fitness-focused devices, such as FitBit. The question hanging over this segment of the telemonitoring universe is when the devices will be sufficiently reliable to enable physicians to rely upon the numbers reported for diagnostic purposes. In the past year, FitBit has been sued in two class actions for the supposed unreliability of its sleep and heartrate data reporting. A turning point in the coming years for wearable technology will be when the Food and Drug Administration (FDA) clear the use of wearable devices as medical devices. Even now, though, research suggests that patients are increasingly self-aware and, as a result, increasingly accurate, in their own reporting of risks, such as hypertension.
- Therapeutic virtual reality
Therapeutic virtual reality (VR) — the use of simulated digital experience for treatment of health conditions — is an intriguing component of the digital health universe. In recent years, VR has received significant public interest around gaming, with more affordable pricing on headsets like the Oculus Rift making the technology increasingly accessible. While therapeutic VR is still in a development phase, it appears to have incredible promise as a treatment modality.
As with telehealth and telemonitoring, therapeutic VR aligns with numerous trends in healthcare, including the shift towards consumer-directed care and greater convenience, and the push for lower-cost solutions. For example, through the development of behavioral health VR modules, patients may overcome anxiety through simulating the anxiety-inducing situation and gaining confidence in their ability to manage it. VR may also be useful as a neurocognitive support tool to help patients sustain recovery from addiction or lose weight.
VR simulations have been used in recent decades in limited ways, such as Bravemind, a VR program for soldiers experiencing post-traumatic stress disorder (PTSD). VR enables health professionals to expose these patients in a safe, incremental manner to the triggers of post-traumatic stress, developing alternative, healthier responses in the process. In coming years we can expect a vast expansion of the therapeutic uses of VR to address a range of mental health issues, including depression, pain management, anxiety and phobias, by offering realistic exposure to the trigger (e.g. heights, flying, insects, etc.). VR may also have significant benefit in applied behavioral health, in developing effective tools for children on the autism spectrum or adults rehabilitating from a range of injuries.
Beyond its therapeutic uses, VR also holds enormous possibilities as a training tool for consumers and health professionals. For consumers, VR may be used for more effective training and education on fitness, wellness, and disease prevention. The next generation of exercise VR will offer immersive, game-like environments to keep people engaged in their activity of choice. For health professionals, VR holds out great promise for cost-effective simulated training for everything from primary care medicine to advanced surgeries.
- Robotic health technologies
Robots are already a significant presence on the healthcare landscape: devices assist the disabled, improve ambulation, speech, hearing, or other physical abilities. In 2014, the FDA approved the marketing of ReWalk, an exoskeleton that allows ambulation by paraplegics. ReWalk is only one example of “rehabilitation” robots as tools that help people with disabilities function. In coming years, we will see a growing range of technologies that enhance human performance.
Through these incremental steps, much of the science fiction about “bionic” human beings who have their abilities not only restored but improved will gradually become a reality. It has been a decade since the futurist Ray Kurzweil published The Singularity Is Near, describing a future of human beings augmented by nanotechnology and artificial intelligence, and while we are not there yet, it is increasingly easier to imagine.
Robotic technologies are not only transforming life directly for patients, but are also changing how health professional practice and how care is delivered, from surgical robots used for minimally-invasive procedures to robotic prescription dispensing systems. One big frontier ahead is the extension of robotics into “micro-bots,” tiny robots injected into the human body to perform a function, such as to confirm a diagnosis, perform an operative procedure, or deliver of a therapeutic agent to a particular site. Another promising area for robotics is infection control, which has been a continuing problem in healthcare facilities. The future will include robots that are able to disinfect equipment and rooms quickly and efficiently, without the risk of human error.
* * *
While the foregoing list is not exhaustive, collectively these trends represent an array of digital technologies that are changing and improving healthcare. Beyond the digital healthcare future, where do we go from here? What should healthcare providers take away from this overview? In my next piece, I’ll offer some thoughts on both questions.