Digital Health seems to have exploded on take-off, but is imploding on landing. We have the technical capabilities to support healthcare without borders, expert patients, and digitization from head to toe... Why aren’t we there yet?
In this article, I intend to condense the current state of affairs in Digital Health—what makes it so beguiling and elusive, and what is yet to come.
In the Great Expectations age, Digital Health continues to challenge the status quo of healthcare, as we know it, by constructing the digitally geared up “new patient”.
This is the age when transformation of healthcare is prophesized. Eric Topol’s book (2012) is mandatory reading for the Digital Health Communication Graduate Certificate (Drury University). In his book, Topol asserts that the “new medicine” powered by the “digitized human” will render “old medicine” obsolete; “[d]octors prescribe medicine of which they know little, to cure diseases of which they know less, in human beings of which they know nothing” (Voltaire in Topol 2012).
When a new paradigm appears, there is intense debate between supporters of the old and the new. Opinion leaders are important because they challenge the status quo and anchor us to the future.
Fig. 1. A few grand personalities in the Digital Health space.
Patient voices begin to be heard due to the push from consumer technologies, the pull from overwhelmed governments, and—last but not least—the democratization effect of the internet. Lucien Engelen conceived the “patients included act” in 2010, which contributed to the inclusion of patients in conferences and in medical publications. Regina Holiday launched the Walking Gallery as a way to communicate patient experience through art. Michael Seres is a patient himself and a patient advocate, but also an entrepreneur in Digital Health. Hugo Campos, also a patient, fights for the right to own the health data generated by medical devices.
In addition, there are communities (i.e. nuviun and several LinkedIn groups: Digital Health, mHealth or Digital Health UK among others) and online publications (some of which are referenced here) dedicated to Digital Health, which facilitate debates and professional connections.
Vocabulary is evolving, proving that Digital Health is at an early stage of industry formation, when the regulatory basis and rules of the game are non-existent or maladapted, and continuously subject to change. Various attempts to clarify terminology have been made, including Rudel et al. (2011), the European Union (2011), COGIR (2011) and, more recently, nuviun’s Digital Health diagram (2014)—which was well received by the market.
Digital Health made it into the academic curriculums, and so it gained recognition and legitimacy as a standalone field.
Institute of Digital Healthcare, Univ. of Warwick, UK - since 2010
CATCH, Univ. of Sheffield, UK – since 2012
Masters in telemedicine and eHealth, Univ. of Tromsø Norway – since 2005
Masters in e-Healthcare, Univ. of Queensland, Australia – since 2003
Digital Health Communication, Drury University, US - 2015
Hand of the regulator and the payer
As I have stated in previous blogs, regulation is important for the maturation of a field. “The EU and the US regulatory landscapes prove that neither early regulation, nor delayed action will best support emerging Digital Health. There is, perhaps, an invitation for regulators to define the basic principles needed to guide coordinated (de)regulation across fields” (Macnaughtan 2014).
One lesson from the Insights Age is that digital solutions do not apply to healthcare as neatly as to the factory floor. The top down approach to healthcare— enforcing change through the iron hand of regulation—needs to be reconsidered.
A recent example is the dissatisfaction amongst healthcare professionals (Stack 2014, Gur-Arie 2015) generated by the Meaningful Use programme launched in 2009 in the US, by CMS and the ONC. As late as this year, an ONC report acknowledges some pitfalls of EHR providers. Albeit only after detailed prescriptions (2015) for digital technology producers were already released by ONC and HHS. Although nobody contests the value of digitizing and exchanging health data, the dissatisfaction indicates that something is still missing; perhaps a coordinated (de)regulation of the healthcare system, or, at the minimum, a good understanding of how available technologies could be used (meaningfully) to match healthcare providers’ needs.
In the meantime, why not enjoy what continues to be an innovative space? There are various options for stakeholders to experiment, interact and learn – accelerators, incubators, conferences or R&D centres (a list from HealthStartup). And, last but not least, government-sponsored collaboration hubs and networks (i.e. Digital Catapult UK, United4Health across the EU).
Then it comes down to the question of who pays for what? This question relates intimately to the regulatory context. In Europe, where the state is often the regulator and the payer, some “governments worry that it could stimulate frivolous demand” (The Economist 2014). However, in the US, for instance, insurers already cover a range of patient remote monitoring services. In this case, “[p]atients [...] may feel they are being fobbed off with second-best” (ibid.). Finally, that brings us back to data: How much is your health data worth? (Juneja 2015).
All rush in...
Market reports from niche companies:
Rock Health (founded in 2010, US)
research2guidance (founded in 2009, Germany)
Market reports from established companies:
Industry associations continue to appear and, interestingly, some converge. Personal Connected Health Alliance is a partnership of HIMSS, Continua and mHealth Summit with the mission to foster the consumer market for mHealth, by promoting the Continua standards.
It’s getting crowded—not only with apps and wearables, but also with new players (pharmaceutical and biotechnology companies, academic institutions, consultancies...).
State, Payers Patients, Doctors, Medical Device Producers, ICT Providers, Digital Health Providers, Pharma, Academic Institutions, Consultancies, Investors
What about the established ICT vendors? All major ICT companies are investing in Digital Health: Qualcomm, Intel, Microsoft, Verizon... and so many others are on standby, most likely to activate once regulators have spoken. There are a few joint ventures (i.e. Caradigm, CareInnovation) and we expect to see more of these (including spin offs). Dedicated platforms are here too: Microsoft Connected Health, Apple’s HealthKit and Google Fit.
It is appealing enough for investors (corporate or venture capitalists) to come running. “In 2014, there were 344 dabbling investors (one or two deals per year) compared to only 121 back in 2011—a nearly 3X increase” [Wang (a) 2015]. As mentioned in my previous post, 2014 blew away the most optimistic funding forecasts [Wang (a) 2015].
Consequently, start-ups benefit from varied sources of funding—from investors to the far end of crowdfunding. Significant investments are going towards companies that develop wearables or digital medical devices (i.e. Scanadu, AliveCor, Cellscope). Another exploding line of business is health data centric. It’s all about the patient, except it’s all about data.
If doctors don’t want us, patients do
Scanadu shows that people want change in healthcare through their Indiegogo crowdfunding campaign (2013). This campaign is the most successful campaign run by a Digital Health company on a crowdfunding platform (at the time of writing, April 2015, source Wikipedia).
There is an ongoing assumption of a dichotomy between digital patients and reluctant doctors. Whilst most of us expect the digital patient to change healthcare, China begins with “digital doctors” (Jourdan 2014). What about empowering both doctors (Rusnak 2014) and patients? See also You, Me and Digital Health.
From the previous age, attention moved on from evidence and one size fits all solutions towards technologies that fit—solutions for contexts—rather than grand solutions (see Tim Ferris and Jacob Sattelmair, Harvard i-lab 2014). It is certainly one way to navigate the uncertainties of a new territory.
Fig. 2. Digital Health’s inflated agenda.
Although it’s in a fluid, alluring, and frustrating state, Digital Health becomes a credible, legitimate approach to changing healthcare. We see the beginning of the maturation of this market. Here, I simply point towards a few indicators.
Although everything seems to begin and end with the patient and data emanating from their body, attention is directed (again) to doctors and healthcare providers [Wang (b) 2015]. This follows the wave of awareness that existing tools fall short of doctors’ expectations and needs, but also the new push from some regulators (US). Hopefully, this will lead to a welcomed deeper understanding of the alleged resistance doctors manifest towards digital technologies.
For technology makers, this age delivers on the promise. Initially, the main business model was B2B (Rock Health 2012). But things change, for instance Personal Connected Health Alliance (2014) aims to nurture a business to consumer (B2C) market. As the market evolves, new distribution channels (NHS apps library or the Cleveland Clinic’s health tools store) and new business models (i.e. Wellframe or IESO Digital Health have primarily a B2B2C model) are opening up.
In 2014, several Digital Health companies go public [Wang (a) 2015]. Mergers and acquisitions intensify, contributing to the coagulation of the market [Wang (b) 2015, Lonzer 2015], and possibly more acquisitions will occur in the US following the “dicta for developers” (Gur-Arie 2015). Before we will see convergence and seamless processes (wellness – disease management – diagnostics – personalized medicine and so on), we will see more fragmentation and differentiation.
Fig. 3. The patient—Alpha and Omega of new medicine. And the rest is (Big, Long) data.
Undoubtedly, all things data—exchange, privacy, security, mining, analytics—will continue to inflate (RWJF 2015). The more advances that occur in the health data arena, the more crossovers will be possible.
Some industries take a few years to mature; others take decades (Aldrich & Fiol 1994). It is difficult to predict how long it will take for Digital Health, but due to the heavily regulated nature of healthcare, it is not likely to happen fast.
The revolution's near or just a little bit of history repeating
(Paraphrase from History Repeating, Propellerheads feat. Miss Shirley Bassey)
In the end, I am afraid there is no revelation. Historically, healthcare has never taken change lightly and, to some extent, for good reasons. I might as well refer to the present as the Big Quarrel, because there is still a gross disconnect between stakeholders (see also Nosta & Montgomery 2015). And without taking each of them seriously, we can’t answer the fundamental questions: what is the role and what are the rights of lay-people in their own (and others) health? (see also Montgomery 2015 and Juneja 2015). Until then, we will experience the “grim reality of Digital Health” (McCollister-Slipp 2014) as a disconcerting web of problems, but fortunately not short in passion (Macnaugtan 2015).
The nuviun blog is intended to contribute to discussion and stimulate debate on important issues in global digital health. The views are solely those of the author.