1. The smartphone
It’s been eight years since the launch of these pocket-sized devices we now know so well. We take them for granted but our phones combine: computing power that could steer a spacecraft, a connection to the internet, a host of sensors for health-relevant data like movement and location tracking, plus a touch-screen interface.
Two-thirds of Britons use them to access the internet (Ofcom Technology Tracker 2015), and few would regard these devices as ‘new’, yet the smartphone’s potential is yet to be realised in health and care.
App stores already feature thousands of health apps, though their uptake for health and care has been patchy. Efforts to curate the best quality apps, for example in the NHS App Library, have had little success so far (Huckvale et al 2015).
One of the more sophisticated apps in use in health care is Ginger.io. In this depression programme, people track their own mood and this is combined with data collected from the sensors in the smartphone about their movements, social app or telephone use. The data can be shared with clinicians and offers people an intervention when their data suggests they might benefit from support.
Smartphones can serve as the hub for sophisticated new diagnostic and treatment technologies. So, for example, people with type 1 diabetes dissatisfied with the progress of medical technology companies are driving the development of an artificial pancreas. This 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 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 data on health problems and their determinants using their smartphones.
The first long-term and large-scale opt-in disease studies are just beginning. Apple seeks to support large-scale studies using patients’ iPhones by providing its ‘ResearchKit’ software platform for researchers to tackle any research question. uMotif is seeking eventually to build a 100,000-person study into Parkinson’s disease, tracking variables using a smartphone app.
2. At-home or portable diagnostics
Devices cheap enough or portable enough to be transported to people’s homes to provide diagnostic information aren’t new – think of a GP doing home visits armed with a stethoscope. But recent innovations mean that devices previously only kept in a hospital or a GP surgery are now portable or cheap enough to be located in people’s homes, and used by patients themselves.
Hospital-level diagnostics in the home
These include portable x-ray machines, 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 we configure our health care system.
At a recent conference at The King’s Fund on emerging primary and acute care systems, Dr Michael Montalto described how these technologies and others enable the safe, high-quality acute care service that his team has provided for people in Victoria, Australia, in their own homes for 20 years. One recent innovation in this area is the AliveCOR ECG embedded in a smartphone case that helps interpret test results via an app and facilitates secure sharing with clinicians (NICE evidence review).
Smart assistive technology
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 their 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.
Verily (formerly Google’s life sciences arm) has invested in a tremor spoon already on the market for use by people with Parkinson’s disease, for example. By incorporating sensors and deploying its data analytic expertise, the aim is to provide people or health professionals with information about how someone’s tremor characteristics and severity change over time – and to understand more about the disease across a population. Smart inhalers like those in development by Propeller Health work on a similar idea, passively detecting each use, location and the surrounding air quality, allowing insights into what triggers asthma attacks.
3. Smart or implantable drug delivery mechanisms
We know that between a third and a half of all medication prescribed to people with long-term conditions is not taken as recommended (Nunes et al 2009). Several technologies in development could enable patients and care professionals to monitor and improve adherence to a prescribed drug regime either through automation or providing better information about medication usage.
One company has developed sensor technology so small it can be swallowed and combined with drugs in pill form. When the pill dissolves in the stomach, the sensor is activated and transmits data to a wearable patch on the outside of the body and on to a smartphone app. This enables patients and their clinicians to see how well they are adhering to their prescription.
Proteus Digital Health began the US Food and Drug Administration (FDA) regulatory process for this technology in 2015. The treatment now undergoing review combines the technology with an anti-psychotic drug, raising questions about how health systems could use the technology and how privacy and autonomy for patients will be affected. The company are also investigating other potential applications including assisting those with long-term conditions such as dementia and Parkinson’s disease to remember to take their medications.
Implantable drug delivery
New automated drug delivery technology is under development by a firm set up by researchers and engineers from the Massachusetts Institute of Technology (MIT). They are developing an implantable device with hundreds of tiny, sealable reservoirs that open when a small electric current controlled by an embedded microchip is applied (Farra et al2012). The team developing the device say it could provide a way to automatically release doses for more than 10 years from a single chip. They are developing the technology for long-term condition medication as well as for contraception.
4. Digital therapeutics
Digital therapeutics are health or social care interventions delivered either wholly or significantly through a smartphone 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.
Many digital therapy platforms include a way for people to connect with peers and share their experience, or to connect with health professionals remotely. Whether they are fully automated or blend automation with supervision, 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 cognitive behavioural therapy (CBT) in the NHS has a relatively long history. Two recent independent studies looking at early-generation computerised CBT suggested that the main limitations in effectiveness were due to people failing to complete the course. Adolescents were more likely to finish the programmes and so benefited more from them. (Gilbody et al 2015, Smith et al 2015).
Recently, a new generation of automated digital therapies based on CBT has been developed that aims to deliver CBT at scale with better engagement. Sleepio is one example, a six-week tailored programme delivered via the web, designed to treat insomnia, and in doing so help alleviate anxiety and depression. There have been positive early results in randomised controlled trials (Espie et al 2012, Pillai et al 2015). 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.
New preventive digital therapies
Another class of digital therapies are in development to help people make changes to reduce the risk of developing long-term conditions. Interventions to change lifestyles through regular coaching and group sessions can reduce the risk of developing diabetes. Sean Duffy, CEO of Omada Health, which delivers online therapies for a range of conditions, gave a presentation at The King's Fund Annual Conference, showing how the company has achieved positive results in its early evaluations in the United States.
5. Genome sequencing
Advances in genome sequencing and the associated field of genomics will give us better understanding of how diseases 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).
Falling sequencing costs
Twenty years have passed since the first complete genome sequence of a living organism was produced and twelve since the first human genome was sequenced. In that time, the economics of genome sequencing has changed significantly. The US National Human Genome Research Institute estimates that the marginal cost of sequencing a single person’s genome has now come down to $1,000. However, the upfront costs are still high and likely to remain so for a long time.
The cost of sequencing could fall further thanks to new sequencing techniques using nanopores developed over the past few years. Nanopores are very small holes that DNA molecules can pass through. When an electric current is induced through the pore, variation in the current as DNA molecules are passed through can be used to infer their make-up. Oxford Nanopore Technologies uses this approach to offer very small genome sequencing devices, far more portable than the larger, fridge-sized machines used in traditional laboratory-based sequencing.
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 government is sponsoring the 100,000 Genomes project in England. Human Longevity Inc in the United States promises to build a database featuring 1 million genomes by 2020 and currently has 20,000 sequenced genomes linked to other data about the person’s physical characteristics. Verily aims, with its Baseline study (a research collaboration between the company and Stanford and Duke medical schools), to analyse large amounts of volunteers’ linked genome, lifestyle and physical data to 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.
6. Machine learning
Until recently, computers weren’t especially good at recognising patterns in messy data. Or rather, the way we 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. 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 these techniques to provide diagnostic support. Enlitic in the United States has created a tool for radiologists that uses previous findings and other data associated with existing images in its databases to spot patterns in images and the data to help spot likely mistakes and rule out extremely unlikely options. Both IBM’s Watson and Google’s DeepMind – the two most famous artificial intelligence organisations – have started to explore potential applications in health care. For example, IBM Watson is studying whether applying machine learning to large amounts of unstructured data like clinical guidelines, scientific literature and treatment protocols could help optimise cancer treatment.
Here at The King’s Fund, we are working with colleagues at Demos’ Centre for Analysis of Social Media to see what is practical and ethical in terms of applying machine learning techniques to user-generated content on the internet. We are hoping to understand the insights that health systems can glean about patient need and how services meet that need.
Blockchains were conceived in 2008 and the most well-known application is the digital currency Bitcoin. The technology has potential uses in a wide range of other fields, particularly financial services and government functions, where it is already being deployed.
Blockchains are decentralised databases, secured using encryption, that keep an authoritative record of how data is created and changed over time. Their key feature is they can be trusted as authoritative records even when there is not a single, central, respected authority updating them and guaranteeing their accuracy and security. This derives from the mathematical properties of the way the data is recorded and the difficulty it would take to break the rules and successfully alter the record.
Decentralised health records
Electronic records for health care are now widely used, but they are stored on centralised databases, secured and provided by a small number of suppliers. Some commentators have described how a decentralised database using blockchain technology to contain all or some of patients’ health information would work, with the patient or clinician given the keys to control who else sees the data.
They argue that the system would be more resilient as no single organisation houses the data and that switching to or incorporating blockchains into existing systems could help to speed up the transition to interoperable patient records. The technology could be applied to create accurate records of health interventions and eventually verified outcomes, which could be used as the basis for reimbursing providers for the health outcomes they achieve for their local population.
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, a shared identity, a social movement, or even just hashtags.
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 the United Kingdom have also become key places for disseminating and discussing health and care information and best practice – as Daniel Ghinn of Creative Health told our Digital Health and Care Congress in 2015.
Communities contributing to research
Some online communities are already 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. PatientsLikeMe has already been used to contribute to nearly 70 published studies, including a study credited with new discoveries about the disease progression of amyotrophic lateral sclerosis (ALS).
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.
With new technologies like these come new opportunities for our health and care system: improving the accuracy and usefulness of information we can gather on our health as citizens and patients; changing how and where care is delivered; and offering new ways to prevent, predict, detect and treat illness.
But along with these opportunities come challenges:
- how to ensure universal access to any benefits through the NHS, ensuring the system doesn’t get left behind by a consumer market and fail to provide poorer or excluded citizens with their benefits
- how to encourage uptake of new care methods and models built around them throughout our system
- how to deal with the great volume of health information these technologies can generate.
The technologies we’ve 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. Ask too much or give too few opportunities for real-world testing and we risk protecting an outdated status quo. Ask too little and we risk spending public money on something ineffective.
Above all we must not lose sight of the people behind the technology and their needs – the patients, citizens and communities for whom it will be put to work.
The authors would like to thank the following: Eric Topol for his insights into blockchain and new directions for digital health; Craig Venter, Ruby Gadelrab and Brad Perkins for a vision of the future of genomics; Pat Saxman, Peter Hames and Sean Duffy for their insights into digital therapeutics; Donald Jones for his insights on drug delivery and patient-driven data; Michael Pellini, Luke Hutch and Joon Yun for helping develop our thoughts on precision medicine; Nick Dawson, Rebecca Hope, Chris Natt and Scott Noppe-Brandon for their expertise on innovation. Rupert Dunbar-Rees and David Ewing Duncan for reviewing early drafts and providing valuable feedback; and Vishal Gulati, Jack Kreindler and Daniel Kraft for their support and assistance in the research phase.
Parts of this idea is 'frightening' it is almost to difficult to comprehend what could be in 'stall' for those individuals suffering from a Mental Illness (LTC) Many patients do not have their medication reviewed for years, often walking around in a 'Zombie' like appearance, denied any offer of New Drugs that could help their condition, and quality of life.
'Implantable drug delivery'?
Not on my 'patch' it is all about 'promoting their product, which saves 'MONEY' by having less Professionals around to do their 'JOB'.
Who is responsible for ensuring the 'Health & Social Care' of the patient now? and who will be in the future if this MAD 'money making' Company have their way? by virtue of a 'Rubber Stamp' by this Government, who are unable to deliver quality 'Health & Social Care' now due to 'Funding'.
'Genome Sequencing' is so far in the distant future as 'every individuals is different. This idea is 'back to front' first find out each person's 'Genome Sequencing', then It is down to the Professionals qualified in their patients illness to decide what is best for their patient.
'Compulsory Treatment Orders' is something I will always be against. I was invited with two other organisations by the DOH to give verbal evidence in LONDON, and still support this today.
I have no idea how they operate CTO when we have 'incapacity' legislation?
'Innovation' is still out there! how can we make it work better?
All those requiring 'Health & Social Care' can be improved, by all those responsible, including Carer's having a 'single' system of communication.
The Computer 'password' entry allows Carers with concerns, GPs Consultant's SW CPN anybody responsible for that person's 'Health & Social Care' 'emergency' 'out of hours'. All Meetings will be recorded in the Computer.
My idea saves the time and energy spent by everybody contacting each Professional individually. Its called 'INSTANT ACCESS'.
Why I favour my idea of Computer access to those responsible for 'Health & Social Care' and their Carers, and my previous idea for Pharmacy access is simple. The Majority of people have a Computer, for those unable to 'operate a smart phone or even own one is even more remote.
The Patient is number ONE, the preferred access is down to them and their ability to 'cope' with a system in their own home is essential, they could be encouraged to input a daily 'diary' in how they are feeling.
A Care Manager Co-ordinator is assigned to a client, daily access to the patients notes.
There is 'innovation' and 'innovation' that allows Companies interested in making money as their number one priority as second to the patient's Health & social Care'.
It is important not to lose sight of the role of the CQC, the 'Protector' from NEGLECT for some!!
Losing sight of ACCOUNTABILITY!
Presumably, the pre-eminent reason for the existence of a National Health Service is to promote health and treat illness, and yet the ubiquitous provision of wifi, smart devices, and other wireless technologies will inevitably achieve the opposite outcome.
Before succumbing to the superficial allure and "convenience" of these technologies, it may be worth remembering (or learning of) a few things.
1) Wi-fi, mobile phones, DECT cordless phones, wireless laptops and tablets, smart meters, smart wearables, even wireless baby monitors, all emit pulsed, modulated, microwave-frequency radiation, which is officially classified by the World Health Organisation / International Agency for Research on Cancer as a possible carcinogen, on the basis that it increases the risk of developing a glioma (see IARC Monograph 102).
2) This non-ionising radiation has been linked to many other health conditions, including autism, ADHD, Alzheimer's, SADS, auditory dysfunction (eg. tinnitus), cognitive dysfunction, dermatological issues, gastrointestinal issues, musculoskeletal issues, respiratory issues, sensitisation, and so on. There are decades of scientific research to back this up.
3) The insurance industry refuses to accept liability for claims related to this radiation. SwissRe categorised it as High Risk in it's 2013 SONAR report, saying: "The ubiquity of electromagnetic fields (EMF) raises concerns about potential implications for human health, in particular with regard to the use of mobile phones, power lines or antennas for broadcasting"
4) There is a long-running legal case, Murray v. Motorola, bought by a number of brain tumour victims, and their surviving relatives, against the telecoms industry for brain tumours which they say were linked to mobile phone use.
5) Two US government departments, the Department of the Interior and the Environmental Protection Agency, have released internal documents in which they note that the exposure standards for this radiation are set on the mistaken assumption that because non-ionising radiation cannot heat bodily tissues by an appreciable degree, then it is therefore "safe".
6) The Parliamentary Assembly of the Council of Europe issued Resolution 1815 in 2011, in which they say: "While electrical and electromagnetic fields in certain frequency bands have wholly beneficial effects which are applied in medicine, other non-ionising frequencies, whether from extremely low frequencies, power lines or certain high frequency waves used in the fields of radar, telecommunications and mobile telephony, appear to have more or less potentially harmful, non-thermal, biological effects on plants, insects and animals as well as the human body, even when exposed to levels that are below the official threshold values".
7) France has outlawed children under three from being exposed to wifi radiation in nurseries and public places, and restricts the exposure of older children.
8) 217 international experts in the study of the biological effects of this radiation have warned the UN, all UN member states, and the World Health Organisation, of an "emerging public health crisis related to cell phones, wireless devices, wireless utility meters and wireless infrastructure in neighborhoods" (see the International EMF Scientist Appeal).
And so on...
Wireless technologies have absolutely NO place in the NHS, and to think otherwise is to ignore the many thousands of scientific papers showing the harmful biological effects, and to throw away any pretence of implementing a Precautionary Principle aimed at protecting everyone - but especially children, pregnant women, the elderly, and those already vulnerable to illness.
Many outpatients lose an entire work shift to display tests to their doctors and have the dose of your medication adjusted. A large percentage of these contacts could be virtual. In fact many of these contacts are already made by WhatsApp, Facebook Messanger, E-mail, SMS or even a phone call.
Patients travel for long periods interrupt their psychotherapeutic treatments because they can not do for Skype, Face Time or other ... That's better than having your virtually session?
Urge that regulate such practices ... It is necessary to discuss with an open mind for this new time. Determine which calls can be made in virtual form, how the calls must be recorded, how the professionals can be paid, how to establish cybersecurity.
We can not ignore the benefits to patient healthcare and better physician results with regulated forms and situations in which the virtual contacts and virtual guidance can or should happen
Many UK companies have fabulous technologies which they manage to sell all around the world EXCEPT to the NHS! The Kings Fund should try and get to the bottom of why the NHS makes it so difficult to deal with and campaign for changes. The loser is the patient and tax payer.
In the section on machine learning you continue to believe the PR put out by IBM about the capabilities of Watson. The FT yesterday ran a very good article about the reality of Watson: http://www.ft.com/cms/s/2/dced8150-b300-11e5-8358-9a82b43f6b2f.html#axzz3wGx9Gpz2
My own UK based company has been providing diagnostic support tools to clinicians and patients for over 15 years. Our main market is....the USA where we have over 150 institutions using it on a daily basis improving the quality of care for US citizens!
I'm currently working on a major HSJ summit on Modernising Healthcare and the role of technology, taking place in May. If you're interested in getting involved in any way, please contact me at firstname.lastname@example.org
Thanks for reading and commenting. Please be assured that we are well aware of the good work being done by Big White Wall and others. Indeed, we referred to them in The Future is Now, a previous publication on similar lines. See http://www.kingsfund.org.uk/reports/thefutureisnow/.
The projects featured here aren't meant to be exhaustive and we can't reference all of the many initiatives out there in the NHS and further afield. I agree with you that one of the biggest challenges is how we commission and deploy these at scale.
Sadly we still have many senior NHS prof's who request emails to be printed before we read them, GP surgeries without patient email access still using fax machines and many surgeries like mine where I can not access my patient records still... forget Skype or Telemed, that's Star Wars fantasy world to them.
Add to that NHS' single biggest investment outside of staffing is in a prescription for a drug - culture and mindset of people needs to shift for digital-revolution to be the game changer it should and could be, if only we stop standing in it's way.
We have moved towards digital only - one can not argue with the scale, pace and transparency of digital / social / mobile can reach.
2 things always at the front of our mind:
1. What do the millennials think/desire/do - a tip we learned from Sir Bruce Keogh when he launched the whole idea of 7 day week at one of the chief execs breakfast meetings we arranged
2. What about disruptive tech eg Uber, Amazon, NetFlix...
it is only a matter of time before an Amazon type org. starts supplying goods/drugs to the NHS right / wrong?
Lord Carter's findings around variations would be eliminated if we used digitech to enable transparency, openness, honesty... the standard principles and ethics that most business are built on (the NHS/public sector like to keep it hidden, force us to make FOI applications, or worse listen to industry when they say 'we can't tell you the price we sold it to your colleagues in the neighbouring trust due to commercial sensitivity, and we wonder why we have publishers like telegraph carrying out undercover operations around alleged corrupt officials, if we were transparent and open they would have nothing to go undercover about!)
While many wait and hide and fight the revolution... the millennial-thinkers are a already building it
Others sectors have used this to drive serious innovation by being able to connect legacy systems.
In a world where we will have little free money surely we should at least aspire to connect previous investment in technology before we adopt the right technologies identified here?
Look at the Patient Relationship Management initiative for NHS111 in London for an example of delivering connected records for urgent care clinicians quickly. Better safer decisions, reduced costs better patient experience. So don't forget to ask for cloud based multi channel technology!
However, we should also keep in mind 3D printing & Big Data
I would be keen to expolre the opportunity to work with other partners to validate this model .
Assistance and advise are welcome.our facility now going on annual mobile services screening.
Help update the service of health care.Thank you
Technology in corporate healthcare is also important for the employee or asset as they stay informed about their physical conditioning. Cognitive health performance is a great example, Cantab Corporate Health (http://www.cantabcorp.com/services) offer services to measure cognitive health for employees ranging from 18+ through to software that looks the cognitive health of employees 50+. By using the apps from Cantab users are able to identify any issues with their cognitive performance which will allow you to take action to manage any issues and boost cognitive performance. This is beneficial for employers and employees as the users could potentially boost their cognitive responses and become more effective, an end result that suits both parties.
This article about modern medical apps
Really, the rapid developement of technology brings innovative solutions in different spheres of life. The medical sphere very important to expect improvements https://erminesoft.com/how-to-build-an-app-with-healthkit/