1. Smartphones and wearables
It’s been more than a decade since the launch of the pocket-sized devices we recognise as smartphones. While they may have originally been perceived as a luxury item, they soon became essential companions. The technologies within these devices have improved iteratively and it is now possible to have access to computing power that could steer a spacecraft, GPS, a high-speed internet connection and high-quality imaging capabilities in the palm of our hands, alongside a host of sensors for health-relevant data (eg, movement and location tracking), plus a touch-screen interface.
Almost four in five of the UK population own a smartphone, yet the use of smartphones in health and care still falls short of the potential to create and monitor personalised digital biomarkers that combine with new data sources to improve prevention, treatment and help people make sustained behaviour change.
Wearable devices are in a newer category of technologies encompassing smartwatches (eg, an Apple Watch), activity trackers (eg, a Fitbit) and connected patches (eg, a smart bandage or smart plaster). These are generally in direct contact with the wearer for long durations, generating large quantities of data on specific biometrics or behaviours. Many large technology companies are positioning these devices as health or wellness devices not medical devices – currently side-stepping regulatory requirements. However, there is potential for these devices to be widely used in health and care, as well as by individuals to improve their health and care. For example, a wearable sensor measuring heart rate can give a truer indication of a person’s heart-rate at various stress levels (sitting, standing, walking, etc) over time instead of a single one-off measure in a surgery which could be erroneous due to patient anxiety or stress.
App stores already feature thousands of health and wellbeing apps, encompassing everything from diet diaries and mindfulness guidance to period trackers and musculoskeletal rehabilitation support. However, the uptake by the health and care system has been patchy due to a range of issues including quality, evidence, clinician knowledge, confidence and skills, and integration into pathways. Efforts to curate the best quality apps, for example, in the NHS App Library, have had little success in making the use of apps for health mainstream. A growing number of apps now focus on a direct to consumer approach largely focusing on health information, self care or monitoring. Apps have also been developed to provide digitally enabled interventions (these are known as digital therapeutics).
The NHS has developed its own NHS App to enable citizens to have easy digital solutions to simple health care needs, such as booking appointments, checking medical records and ordering repeat prescriptions. This could be the first step in creating an app-enabled health care system with the NHS App acting as a front door. Online consultation providers (such as eConsult) are being integrated with the NHS App, supporting triaging and allowing text messaging with health care professionals to be more easily available. Personal health record (PHR) services, such as Patients Know Best, are now also integrating with the NHS App. PHRs can bring together the fragmented health and care of an individual into one record held by the individual themselves. Combining services and PHRs with the NHS App supports the move to person-centred care and multidisciplinary care provision. As more services are able to integrate into the NHS App, the functionality will become richer and more personalised to the individual’s health and care needs as well as their capabilities.
Smartphones combined with the cloud can serve as the hub for wearables, connected devices, data and sophisticated new diagnostic and treatment technologies. For example, people with type 1 diabetes are driving the development of an ‘artificial pancreas’ which links continuous glucose monitoring and insulin-delivery systems that are all controlled by the smartphone. It will adapt its algorithms for insulin delivery to a person’s physiology.
Smartphones and wearables are highly effective data collection devices, and they can record a lot of detail about people’s lives. As well as tracking their own health status, people can also help researchers gather large amounts of real-world data on health problems and their determinants using their smartphones or wearables.
Apps are now being created specifically for medical research, thanks to open-source frameworks (such as Apple’s ResearchKit, and ResearchStack for Android devices) that have made it possible to more easily transfer apps from one platform to another. These apps are able to survey users and enable them to opt-in to research through consent forms, as well as supporting the sharing of data automatically gathered on their devices such as step counts, heart rate, etc. These platforms have sparked a new approach to disease study, with a number of long-term and large-scale opt-in studies completed since 2015. For example, more than 4,000 people enrolled for a Parkinson’s disease study in 2016, more than 400,000 people enrolled for a atrial fibrillation study in 2018, more than 8,000 people in a asthma study in 2017, and 250 people are being identified in 2020 for enrolment as ‘citizen scientists’ for a study on adolescent arthritis.
The sheer numbers recruited over a short period of several months wouldn’t be possible without a digital app-based approach. These studies have the potential to create understanding of how disease varies over time and the associated lived experience of individuals, and have improved the use of smartphones and wearables as digital endpoints for medical research. In future researchers will be able to create personal baselines using this data, quantify an individual’s lived experience, track the digital biomarkers that can improve diagnosis and accurately monitor disease progression and treatment efficacy. These features remain tantalisingly out of reach for the time being.
Most, if not all, digital tools and technologies are dependent on infrastructure (devices, connectivity, sensors, etc) to function. Infrastructure, in the form of the hardware running the software tools, and connectivity to the internet are absolutely essential for modern digital tools. But health and care systems are often held back by cheaper or older hardware with limited functionality and poor connectivity.
Virtual machines offer an alternative approach that works in a similar way to screen sharing in video calls. The difference with virtual machines is the screen sharing occurs with a computer in the cloud, which the user can control. This means the internet connection only needs to transfer the screen image and some control information (eg, if the user taps on an onscreen button) requiring lower internet speed and data. It also means that the user hardware needs to do less processing so can be less prone to crashing, stalling, etc. Using virtual machines offers a way of overcoming the issues associated with older or lower capability hardware. In health and care systems where resources are tight and infrastructure can be generations behind consumer technology, virtual machines could enable digital to leap forward and meet patient and consumer demands.
2. At-home or portable diagnostics
The response to the Covid-19 pandemic has seen a massive shift towards telemedicine replacing face-to-face contact. Current solutions mostly focus on enabling communication virtually. However, there is potential to further improve and differentiate telemedicine by adding functionality in the digital realm that isn’t possible in the physical consultation room. For example, live image tracking could easily quantify a patient’s mobility, which isn’t possible in face-to-face consultations. In the future functionality could also enable colleagues to drop in to virtual consultations providing coaching, mentoring and peer support.
Connectivity has become almost ubiquitous, now that devices such as e-stethoscopes, connected blood pressure monitors and connected pulse oximeters are readily available. They are cheap enough to be affordable for many patients or are readily available for clinics and surgeries to provide to patients for short-term use at home.
Hospital-level diagnostics in the home and community
Diagnostic tools once found in hospitals, can now be used in the home and the community. These include portable x-ray machines, ultrasound equipment, blood-testing kits and other technology that can provide more and more of the diagnostics required to support health care, with profound consequences for the way the health care system is configured.
Butterfly IQ is a point-of-care ultrasound system which has a specialised ultrasound probe that leverages a smartphone (or tablet) to provide the computational processing, connectivity and display – in combination creating a highly portable point-of-care ultrasound system. The smartphone (or tablet) also enables new functionality such as virtual support from a clinical expert.
Many people with disabilities or long-term conditions use assistive devices to help them perform tasks or activities made harder for them by their disability or condition. These are often available as part of NHS and social care packages. The prospect of using these to gather information in addition to achieving a specific task is motivating several new developments.
Smart inhalers like those in development by Propeller Health work by passively detecting each use, its location and the surrounding air quality, allowing insights into what triggers asthma attacks. Seeing AI is another example of smart technology, which describes nearby people, text and objects to support the visually impaired.
3. Smart or implantable drug delivery mechanisms
Between a third and a half of all medication prescribed to people with long-term conditions is not taken as recommended. Several technologies in development could enable patients and care professionals to monitor and improve adherence to a prescribed drug regime either through automation (see implantable drug delivery) or providing better information about medication usage (using smartphone reminders and location information).
Implantable drug delivery
Several new drugs and biologics have poor solubility, which makes administering them difficult – it can be time consuming, uncomfortable and highly variable. Technological developments have prompted renewed focus on new approaches to delivering these drugs at the point of need. Implantable drug delivery approaches provide the drug locally, minimising side effects that can occur when medication is taken orally or injected. Existing technological methods for delivering drugs include drug eluting stents, balloons and sinus implants, but new automated drug delivery technology is under development. Researchers and companies are developing implantable devices with hundreds of tiny, sealable reservoirs that open when a small electric current, controlled by an embedded microchip, is applied. The vision is that such devices could provide a way to automatically release doses for more than 10 years from a single chip.
The next stage of development will be to make these devices using new materials that are bioresorbable – that is, the material essentially dissolves once drug delivery is complete, negating the need to retrieve the device. Microchips are also driving the development of more sophisticated closed-loop systems to connect with smartphones and improve dosing.
4. Digital therapeutics and immersive technologies
Digital therapeutics are evidence-based health or social care interventions delivered either entirely or mostly through a device (a smartphone, tablet, virtual-reality or augmented-reality system, or a laptop). They effectively embed clinical practice and therapy into a digital form. At a minimum, these interventions combine provision of clinically curated information on a health condition with advice and techniques for dealing with that condition. For example, a clinician could prescribe a person with a history of depression or anxiety an app that incorporates, for example, breathing exercises, meditation or cognitive behavioural therapy (CBT). Such an app could give regular support alongside self-care to help the person overcome episodes of depression without needing to seek in-person help and wait for an appointment.
Whether fully automated or blend automation with supervision (or coaching), the therapy offered can be tailored to the needs of the specific user. Digital therapeutics are often cited as a solution to help manage long-term conditions that call for behaviour changes or to prevent diseases in the long run.
Computerised cognitive behavioural therapy
The use of computerised CBT) in the NHS has a relatively long history. A recent independent study looking at early computerised CBT has suggested that the approach was limited in its effectiveness because young people failed to complete the course.
Recently, however, a new generation of automated digital therapies based on CBT has been developed, which aims to deliver CBT at scale with better engagement. Sleepio is one example: a six-week tailored programme delivered online that is designed to treat insomnia and, in doing so, help alleviate anxiety and depression. There have been positive results in randomised controlled trials. The therapy is personalised in response to data provided by the patient, and by using the latest practice in design and delivering the therapy via an animated avatar, the course is made more engaging. Design and personalisation are key elements likely to improve engagement, and therefore outcomes, in digital therapies of all types
Virtual-reality and augmented-reality technologies have been on the cusp of widespread consumer adoption for many years but have yet to be realised despite significant advances in the technology. Virtual and augmented reality have the potential to build further on digital therapeutics to improve accessibility, features and outcomes. These tools will provide immersive and personalised health care access using more sophisticated digital therapeutics than today all in the comfort and convenience of an individual’s home.
Virtual reality has potential to be applied to several areas such as pain management, eating disorders and rehabilitation. Virtual reality is fully immersive – it blocks off sound and sight instead providing the patient with computer-generated imagery and noise. This means a patient can be immersed in a virtual world that can help to manage pain, provide scenarios to change behaviours or games to improve mobility.
Augmented reality is being explored as an approach to improving quality of surgical interventions through two means: training and live guidance. Augmented reality overlays computer-generated features such as arrows or text over what can already be seen around us. It can be applied to training to improve how surgeons perceive and interpret anatomy during interventions. Augmented reality can also help by identifying what a clinician is seeing to guide an intervention. This could be through software that automatically recognises specific parts of the anatomy to highlight specific features of interest or alternatively could involve a more experienced peer joining remotely and annotating the live shared video to support and coach colleagues.
5. Genome sequencing
Advances in genome sequencing and the associated field of genomics will give us better understanding of how diseases and medications affect different individuals. With the genetic profile of a person’s disease and knowledge of their response to treatment, it should be possible to find out more about the likely effectiveness of medical interventions, such as prescribing drugs to treat a disease (pharmacogenomics).
The first complete genome sequence of a living organism was produced in 1995, with the first human genome sequenced in 2003, costing approximately $2.7 billion over a decade. Since then, the economics of genome sequencing has changed significantly. In 2003 it was commonly believed that a $1,000 genome sequencing cost would unlock personalised medicine. With the cost now trending towards a few hundred of dollars this aim has been surpassed. However, we are yet to see the dramatic impact of genome sequencing because the upfront costs for equipment and training for interpreting the complex genome are still high and likely to remain so for a long time.
The cost of sequencing could fall further thanks to new sequencing techniques.
Major projects are under way internationally to gather large databases of genomes and analyse them to find relationships between genetic make-up, people’s disease risk and experience, their physical characteristics and their behaviour.
In the United Kingdom, the 100,000 Genome Project, announced by then Prime Minister David Cameron in 2012, achieved its ambition of sequencing 100,000 genomes in 2018. The NHS in England has since established the Genomic Medical Service, comprising laboratory services, directories, sequencing provision and informatics infrastructure to apply the advances to improving the care of the nation. In 2020, the government published Genome UK: the future of healthcare, a vision to build on the 100,000 Genome Project with focus on diagnosis, screening and research.
In the United States, Project Baseline (a research collaboration between Verily Life Sciences and Stanford and Duke medical schools) is analysing large amounts of volunteers’ linked genome, lifestyle and physical data. The initiative will develop a better understanding of how all that data looks when a person is healthy and identify the changes that indicate disease at an earlier stage than currently identified.
Genomics provides insight but it is one part of a bigger picture, often family history, socio-economic and environmental factors can have as important if not more important influence towards an individual’s health. New tools and approaches need to be developed and implemented at scale to bring these different datasets together. The Accelerating Detection of Disease initiative sets out to do just this. Partially funded by UK Research and Innovation the initiative will link datasets for five million individuals to detect and prevent the development of diseases. This huge interlinked dataset will completely change how we view and treat disease risk, prevention and prediction.
6. Artificial Intelligence
Artificial intelligence (AI) is an umbrella term encompassing a number of different approaches where software replicates functions that have until recently been synonymous with human intelligence. This includes a wide spectrum of abilities such as visually identifying and classifying objects, converting speech to text and text to speech, etc. The NHS AI Lab launched in 2019, with the aim of supporting AI development in the NHS and addressing challenges in implementation with AI tools in health care.
Until recently, computers weren’t especially good at recognising patterns in messy data. Or rather, the way people programmed them meant they weren’t very good. New techniques have now been developed in the applied mathematics and computer science fields that have allowed more effective use of computers for tasks like this. In combination with the development of graphical processing units, artificial intelligence has benefited from a renewed focus and increasing funding, unlocking insights in large and complex datasets. Machine learning is one such field. It is a type of artificial intelligence that enables computers to learn without being explicitly programmed, meaning they can teach themselves to change when exposed to new data.
New insights into big datasets
Several new businesses hope to use machine learning techniques to provide diagnostic support to improve care delivery. For example, Deepmind has published research evaluating AI applied to breast cancer screening showing improved efficacy, and startups, such as Ultromics, are applying machine learning to improve speed and reduce variability in the diagnosis of cardiovascular disease from ultrasound images. In the future, machine learning tools will be able to quantitatively interpret images to create digital biomarkers that predict onset of disease. The EVAREST study is a multi-centre trial aiming to validate blood and imaging biomarkers, the first step to achieving diagnosis based on machine learning-powered digital biomarkers.
Many of these tools use machine learning but not adaptive algorithms, which continuously learn and change with use. If the regulatory, safety and cultural issues can be overcome in future there will be software that changes and improves dynamically with each use.
Natural language processing
Verbal and textual sharing of information is complex, with nuance in sentence structure and choice of words – there are an almost infinite number of ways of saying a sentence. This makes it very difficult for a machine to understand written or spoken sentences. Natural language processing is a sub-category of AI that focuses on how to programme software able to process, analyse and respond to the spoken or written word. It is still a nascent field, but one with huge potential for health care. For example, Microsoft is looking at how natural language processing can automatically capture consultation information for electronic health records and IBM is developing chatbots to improve information awareness for frontline staff at the Royal Marsden Hospital. In the future, computers that can interpret, store and show relevant information will improve efficiency and reduce burden in the health care system. Tools like this can also help to engage a person in their own health by overcoming health literacy and literacy barriers.
7. Robotics and automation
The ongoing miniaturisation of electronics and motors over several decades has enabled the creation of more complex and capable robotic systems. When combined with sophisticated sensing technologies, medical imaging data and safety mechanism they have the potential to be used in health and care settings. Robots have multiple unique benefits such as no fatigue, the ability to lift heavy loads smoothly, not being damaged by x-ray radiation, the ability to replicate tasks with high degrees of precision, and can be many different shapes and sizes. With these benefits and flexibility, there’s potential for robots to be used to improve diagnosis, interventions and care provision in health and care settings. This could span simple tasks, such as helping porters move patients, to advanced applications involving surgical interventions.
Robots can be developed with more dexterity and degrees of motion than people and, more importantly, more arms. In the near future, hospitals could be using a multi-arm robot to hold several ultrasound probes at once to carry out multiple foetal ultrasound images, enabling more accurate and higher quantities of foetal images. Improved image quality and quantity will enable improved image processing and interpretation, with the potential for identifying problems that might currently be missed. The iFIND project is aiming to do just this. With £10 million funding from the Wellcome Trust and the Engineering and Physical Sciences Research Council, the project aims to enable a high-quality scanning service that does not require expert sonographers during routine scans, with ultimately fewer babies with major problems missed.
Robots are potentially well suited to carrying out minimally invasive surgery due to a high degree of precision. ‘CE’-marked robotic systems conforming to European standards for health, safety and environmental protection are readily available but could need further development to improve outcomes beyond traditional (non-robotic) surgery to justify the high cost of the system. Robotic systems have the potential to improve the consistency and quality of surgery and may enable surgeons to use their clinical judgement and expertise to carry out interventions that are currently not possible.
Some types of heart surgery require the use of ultrasound imaging during live x-ray interventions. This means a nurse or other highly qualified member of staff needs to hold the ultrasound probe while wearing lead apron to protect them. Lead aprons are heavy and cumbersome, and as they are not entirely effective the member of staff still receives some x-ray exposure. Holding the probe for the duration of the intervention can be tiring and motion can result in delays or even errors during surgery. In the future robotic devices could be used by nurses to control hold and position the ultrasound probe while keeping the nurse safe from unnecessary radiation exposure.
8. The connected community
Behind all technologies, there are people. The internet and the devices and technology it has enabled have facilitated the development of many communities, bringing together people around a common interest, shared identity, social movement, or even just a hashtag.
Peer-to-peer support networks
Connected communities for health are growing in their membership and their diversity. Several platforms bring together people with interests in health and care within countries and across the world to support each other, share learning and even provide a platform for tracking their health data or helping them manage their condition.
MedHelp, PatientsLikeMe and HealthUnlocked are just three of these social networks for health. Alongside these dedicated networks, platforms such as Twitter and Facebook that dominate the social network market in many countries have also become key places for disseminating and discussing health and care information and best practice. Closed Facebook groups for clinical conditions have been established by patients, hospital clinics and GP surgeries to improve health literacy and support patients to make informed decisions on their own wellbeing. Closed groups can result in the sharing of misinformation, however groups set up and managed by trusted organisations such as health care providers and charities can counter this by providing trusted information at patients’ fingertips and enabling group support.
Communities contributing to research
Some online communities are contributing to research about their health conditions, offering people the chance to be ‘data donors’ and providing a simple way to share their data with researchers. Data from PatientsLikeMe has contributed to published studies, in multiple clinical areas including depression, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS).
HealthBank offers a different model and is described as ‘the world’s first citizen-owned health data transaction platform’. Members pay a one-off fee to store health data securely and control who it is shared with. The organisation is a co-operative, so profits made using the patient data are paid out in dividends to its members.
Advances in technology provide the opportunity to reconsider what good-quality, effective health and care looks like. Technology can improve access to information to enable better decisions about what will work for an individual and can enable individuals to have more control and knowledge about their health.
But along with these opportunities come challenges. Technology works for some but not everyone, and is affordable to many but not all, so it is important to ensure that embracing technology does not exacerbate inequalities or create new ones. The most precious resource in the health and care system is its staff, and technology needs to work for them and for the individuals receiving care. Technology is enabled by infrastructure and the skills and expertise of the users, which will require investment if the benefit of these tools is to be realised.
The technologies highlighted here are not an exhaustive set. Many of them could transform health and care but more evidence is needed on their costs and benefits to deliver on their promise. Asking too much or giving too few opportunities for real-world testing could protect an outdated status quo. Asking too little could risk spending public money on something ineffective.
Above all the health and care system must not lose sight of the human need driving use of technology to improve outcomes, quality of life and the care it provides with the limited resources available.
Really enjoyed this updated review and agree with many comments- especially Esther's re the need for cultural change - - -.My book "Health & Social care in the digital world"2020 Tayolr & francis developed four key themes - The empowered citizen, redfined professionalism, mutuality and organisational integration the digital age has many dimensions to cover and much more is left to unfold
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Thanks for taking the time to write this. It is important information. Keep it up!
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