More than 80 percent of people in the UK own or have access to a smartphone, including 65 percent of those between 65-75 years of age1. Worldwide there are over 300,000 health apps, with more than 200 new apps being added each day2. There are currently over 300 different consumer health devices available, ranging from smartwatches and fitness trackers through to connected biosensors that transmit information wirelessly to mobile apps. Given these statistics it is hardly surprising that many believe that harnessing the opportunities created by technology
will be essential if the NHS is to manage the challenges ahead.
Although there seems to be widespread agreement over the importance of digital health tools, implementation has been slow, high profile failures continue to be reported3, and key questions remain: How can technology redesign care, and how can obstacles to its adoption be overcome?
Apps and digital monitoring
Whilst digital health tools encompass a wide range of technologies, mobile apps form the core of many offerings. General wellness apps account for the majority of health apps available to consumers. However, apps focused on specific health conditions form a rapidly growing sector. Several of these apps have an evidence base approaching that required for adoption into clinical guidelines.
At present, the majority of wellness apps are downloaded by people independent of health care professionals. This has raised concerns about the “inverse care law”, where those in greatest need get the poorest access to healthcare. In response, Public Health England and others are starting to encourage and promote the widespread use of high-quality wellness and prevention apps. Perhaps this is not surprising given that payers with long-term budget responsibilities are likely to benefit the most from what these apps have to offer, through the creation of a true “health service” as opposed to a “sickness service”.
The NHS Apps Library (see p30), launched in April 2017, can be expected to play a key role in this transformation by helping citizens navigate the bewildering array of varying quality apps.
In addition to the wellness apps there are many condition-specific apps providing tailored education and support management. Apps can also play a key role helping patients and carers track their condition over time. For example, the Start app helps people monitor the effectiveness and adverse effects of antidepressants. This helps them assess whether they’re feeling better and creates a feedback loop between the medication, the condition and the patient’s experience.
Biosensors in combination with apps and mobile devices offer a powerful range of remote monitoring approaches. Such combinations can remotely capture patient specific data, analyse the data using powerful algorithms and alert physicians, health care professionals (HCPs) and care managers only when pre-set limits are passed. Remotely or face-to-face targeted interventions can then be made to avoid clinically significant sequelae.
East Lancashire Hospital NHS Trust conducted a trial using digital monitoring to measure key parameters of patients with chronic obstructive pulmonary disease (COPD) at home. This data was sent to a virtual ward using a landline or mobile where a clinician reviewed the results, enabling early intervention in those with readings outside a predetermined range. The trial showed significant reductions in admissions, lengths of hospital stay and reduction in home visits.
Rehabilitation
Rehabilitation is a key component of the management of a number of conditions. However, there can be inadequate access to rehabilitation services or patients frequently drop out early due to the demands of attending centre-based services. Through the Innovation and Technology Tariff, NHS England funds licences for the myCOPD app. This has been shown to be as effective as traditional centre-based programmes4 for patients with a diagnosis of severe/very severe COPD.
Similarly, capturing data through activity monitors linked to apps could play an important role in encouraging and monitoring activity and pain in the weeks and months after joint replacement surgery. This would help ensure the benefits are maximised.
Medication
A range of digital health tools have emerged to help patients find the best price for medicines, manage repeat medication ordering and polypharmacy to improve primary medication non-adherence.
A wide range of digital tools are also available to support medication adherence. eCAP, Dosemetrix and similar devices record when patients access their medication either by removing a bottle cap or pushing a tablet or capsule from a blister. Whilst this does not necessarily mean the patient has taken the dose they are a useful tool to monitor adherence. Ingestible sensors such as Proteus, embedded into a solid dosage form, are activated in the stomach. They transmit a signal to a patch worn by the patient and an app on a mobile device records and transmits information confirming the medication’s ingestion. The FDA has recently approved Abilify Mycite, the first such drug-device combination.
Other approaches to adherence support include the AiCure mobile app, which uses artificial intelligence to visually confirm medication ingestion.
Achieving integration
With such a wide range of options already available, the challenge for any healthcare system will be to focus on just a few systems to avoid an unmanageable range of systems needing to be integrated into care. Similarly, the life sciences industry will need to focus efforts towards a standardised approach if we are to avoid making the medication regimen of patients with chronic conditions requiring multiple medications even more complex.
A logical extension of these digital tools is their expansion into strengthening outcomes-based commissioning and reimbursement. Whilst many agree that reimbursement based upon the health outcomes delivered makes sense, the practical challenge of capturing some of these has been a barrier to widespread adoption. As we have seen, digital health tools can capture outcome measures such as mobility, quality of life, pain scores and symptom diaries with minimal disruption to either patients or the health service.
Randomised controlled trials (RCTs) have and will remain key to the advancement of medical knowledge. But real care doesn’t take place in the artificial world of an RCT. Remote digital tools are already revolutionising the capture and analysis of outcomes within the real world through the collection of patient-reported outcomes. But the technology also allows capture of physician-reported outcomes. For example, we recently demonstrated that complex blood chemistry results and medications can be captured and entered automatically into a study database by participants using an app and the camera on their smartphone. Patient-powered long-term registries can be expected to expand our understanding of the natural history of a wide range of conditions.
However, as with other disruptive innovations, a number of barriers to the widespread adoption of digital health tools remain.
Physicians and HCPs remain concerned about the review and recommendation of apps to their patients. Concerns about data privacy hit the headlines almost weekly. With social apps now included in these data breaches, the level of trust rightly impacts digital health tools given the confidential and private information they manage. Adoption also raises resourcing concerns, not just about the initial investment but also ongoing maintenance and updates. In addition, once embedded into routine care, there is the question of whether the health service will be vulnerable to price hikes in the absence of control mechanisms. Critically, those designing care must consider whether the digital tool should enhance the current approach to care or enable existing workflows to be redesigned.
To truly grasp the opportunities being created demands a clear policy direction linked to the benefits that will be created for patients, physicians and HCPs, healthcare systems and the health of citizens more generally. Inclusion within traditional clinical guidelines will allay some concerns, but the infrastructure that supports safe care now must evolve to encompass both the new digital tools and the way they will be used.
Martin Parkinson is a life sciences expert at PA Consulting Group
