What’s holding digital health back, when its future appears so bright? In this first of two articles, Lorena Macnaughtan starts from the very beginning, taking a look at the roots of the digital health movement.
They say the next big thing is here
That the revolution's near
But to me, it seems quite clear
That it's all just a little bit of history repeating
History Repeating, Propellerheads feat. Miss Shirley Bassey
Healthcare without borders, expert patients, technology from head to toe... In the midst of defining and redefining what Digital Health is and what it can do for us, let’s start from the very beginning.
Fig. 1. History of Digital Health
Prehistory (1897 - 1985)
First, there was telemedicine... Darkins and Cary (2000) find that the first remote diagnosis reported in a journal was in 1897, when a child is diagnosed with croup cough via the telephone. Between the mid ’70s and the mid ‘90s, the interest in telemedicine is conserved for space and Antarctic expeditions, remote explorations or military interventions (ibid.). Imaging technology benefits most from digitization. Two significant industry associations are founded: COCIR (1959) and HIMSS (1961).
The Hit Wave (1985-1999)
This age is dominated by lateral creative thinking, the era of managerial visions and magic changes. “One size fits all” solutions are tested, not only related to information and communication technologies (ICT), but to many areas of healthcare. However, the ICT visionary bubble is not sustained because of a general disconnection between the main stakeholders - the ICT and medical community.
State, Payers, Doctors, ICT and Medical Device Producers
Nonetheless, several professional associations appear, i.e. the International Medical Informatics Association (1989), the American Telemedicine Association (1993), the UK Telecare Services Association (1995), and EHTEL (1999). A few health information providers set ground as well (i.e. WebMD in 1996, Medline Plus in 1998).
Towards the end of this period, the demise of managed care makes the patient more visible. “The shift to consumerism is driven by a widespread scepticism of governmental, corporate, and professional dominance; unprecedented economic prosperity that reduces social tolerance for interference with individual autonomy; and the Internet technology revolution, which broadens access to information and facilitates the mass customization of insurance and delivery” (Robinson 2001).
The Insights Age (2000 - 2009)
At this stage, there is a general impatience with digitizing healthcare. Several national Electronic Health Records initiatives are deployed with success (Israel), and relative success (Canada) — but mostly with sound failure (i.e. UK, Germany, Australia).
A lot of effort is put into assessing the benefits of telehealth and telecare programs. “Evidence is the name of a battle that has been won” concludes Nicolini (2009) — because healthcare innovation is a political process in which scientific arguments represent only a forum for debates.
Fig. 2. eHealth’s (the popular term now) growing pains.
In January 2008, the European Union (EU) launches the Lead Market Initiative, where eHealth is identified as one of the most promising markets. The Health Information Technology for Economic and Clinical Health Act (2009) sets an agenda for the US to invest in promoting the use of ICT in healthcare. In the same year, a first of its kind industry event, the mHealth Summit (US) gives the market a positive indicator.
State, Payers, Patients, Doctors, ICT and Medical Device Producers
Imaging technologies, health content providers (i.e. WellDoc founded in 2005) and patient networks (i.e. PatientsLikeMe founded in 2004) are the main beneficiaries of this period. There are only a few wireless sensing device companies, i.e. Monica Healthcare (2005) in the UK, or Fitbit (2007) in the US.
“Issues of scale and complexity in healthcare are only just beginning to be understood in relation to eHealth” (EHTEL 2009). During this age, it is acknowledged that despite notable national ICT failures, the future of healthcare will require a digital framework. Additionally, there is a realization and understanding that the use of ICT in healthcare will include the need to address specific requirements—such as infrastructure, interoperability, legal issues, etc.
There is an overall sense of disillusionment, which carries over to the next age (see also EHTEL 2009).
The Great Expectations Age (2010 – ...)
The pervasiveness of technology (mobile devices, open source, APIs...) converging with the urgency of overwhelmed governments burdened by demographic issues leads to the emergence of lay-people at the forefront of the Digital Health vision.
What we see now is an intense interaction between stakeholders and industries, and an emerging/exploding market at the crossroads between consumer digital technologies, medical devices and healthcare.
State, Payers, Patients, Doctors, Medical Devices Producers, ICT Providers, Digital Health Providers, Pharma, Academic Institutions, Consultancies, Investors
It’s getting crowded, not only with apps, wearables, and insideables, but with new players (pharmaceutical companies, academic institutions, etc.). Platforms are emerging too - Gemalto’s M2M platform, Microsoft’s Connected Health, and Apple’s HealthKit, as well as Google Fit.
2014 proved an unexpected appetite for investments, reaching $4.1B, “nearly the total of all three prior years combined” (Rock Health 2015). The European Union (2014) estimates that the mHealth market will reach over 17 billion Euros by 2017, whilst, by 2018, the wearable market alone is estimated by Statista (2014) to grow to 13 times its 2013 size.
Regulations have a strong impact on markets and innovation. Therefore, many innovators turn now their attention to the actions of the state. Whilst the European Union (EU) and the US have made attempts to regulate some aspects of Digital Health, other countries seem to either mimic them (India and China for instance), or have no regulations at all (PwC 2013).
The EU, somewhat belatedly, launched a public consultation on mHealth in April 2014. The results are to be presented in Riga, during the eHealth Week, in May 2015. Compared to the FDA’s dance to regulate and deregulate various aspects of health IT and mHealth, the EU does not rush things through. Whatever the case, regulations or lack of, there is no great sense of relief (see also my post What Have the Regulators Ever Done for Us? 2014)
Whilst the previous age was devoured by evidence, this is not the name of the game anymore. At the moment, there is no single mantra for Digital Health, but a web of interconnected matters to solve:
Fig. 3. Digital Health’s inflated agenda
Presently, Digital Health is emerging as a standalone market, with multiple stakeholders stumbling in uncertainties and debates. Whilst the digitally geared up patient/person is still waiting for a role to be written, Digital Health will find its way only by negotiating a new logic of health, wellness and care (see also Digital Health’s Growing Conundrum: The Ethics of Everything, Montgomery 2015).
In my next post, I will examine the current state of Digital Health and what is to come.
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.