Long Read

Digital Health: where AI meets EI

Digital health holds out the promise of great rewards for patients and populations and, if they get their strategies right, for businesses of many different sorts. It is not, however, a panacea or a silver bullet.  It brings with it new risks as well as opportunities.

The Two Meanings of Digital Health

As an African friend told me, digital health has two meanings and only one is about technology. The other is about hands-on care. It is an interesting to note that as science and medicine become more powerful and offer us precision medicine and personalised drugs, social changes such as ageing, migration and the spread of Western lifestyles are making the treatment of diseases more complex and bringing health promotion and disease prevention to the fore. We are experiencing great scientific advances in health, but we are also seeing an increasing need for care, empathy and societal action to improve it. Artificial intelligence (AI) will be very important for our health but human intelligence and emotional intelligence (EI) will be needed even more than ever.

This is part of the bigger picture of how societies and economies are changing. As the Governor of the Bank of England said in a recent speech on the Fourth Industrial Revolution: “just as workers once had to shift from using their hands to using their heads, as machines took over …. workers (in the future) would have to adjust again from using their head to using their hearts.” He went on to say that while there would be jobs lost in many sectors the jobs left would be ones that “require emotional intelligence, originality or social skills such as persuasion or caring for others.”[i]

Artificial intelligence will be very important but emotional intelligence will be needed even more than ever.

We are all now familiar, if only from the media, with the idea that AI, information and communications technology, genetic therapy, engineering, nanotechnologies and other scientific and technological advances will both enhance our capabilities and transform the way health care is delivered. There are already many examples from around the world where this is happening. The home monitoring of patients’ blood pressure or heart rhythms, for example, is becoming commonplace. In Kenya midwives can now perform ultrasound examinations of pregnant women in rural villages using portable scanners and send the images directly to the regional centre for real-time interpretation.   There has been an explosion in the availability of evidence-based protocols, in both industrialised and developing countries, which guide clinicians through the appropriate steps to take in diagnosis and treatment of specific conditions.

These examples are only the beginning of increasingly dramatic changes. There are already pumps that can be fitted internally to sustain a failing heart, and micro-pumps to facilitate blood flow within veins are in development. Most radically of all, but also the most uncertain, is the potential that AI has for improving diagnosis and the discovery of new treatments. AI offers the ability to analyse enormous volumes of anonymised patient data to detect patterns and develop software which can be used by patients or clinicians for diagnosis. This can then be combined with other data to create phenotypic data sets which can be analysed to answer clinically relevant questions and identify potential new treatments.

Transforming Health Systems

These developments are important in themselves and in combination could eventually lead to the transformation of the whole health system. They will change not only the individual elements of care but change the way care is delivered, how governments promote healthy populations and how we individually strive to become and remain healthy.

They mean, for example, that care can be delivered in different locations – challenging the central role played by hospitals. Many tests, procedures and diagnoses can be carried out by different staff groups – challenging the roles built up over many years by specialists, particularly doctors. Patients, their families and carers will be more involved – challenging health workers to think and behave differently.  Many different players will be involved in promoting health and delivering care – challenging the monopoly of the traditional health providers.

It seems that the Fourth Industrial Revolution may at last lead to the modernisation of the whole health sector which commentators have called for over many years.  We can expect to see the impacts of disruption, new entrants, new technology, de-layering, de-specialisation and all the other concomitants of modernisation that other sectors have seen. However, I would argue that there will be some key differences in how this happens in a sector where people and their values and choices play such a significant part and where the actions of all sectors of society impact outcomes.

These technological changes are not the only drivers for change in health systems. There is a massive increase in non-communicable diseases such as cancer, heart diseases, diabetes and dementia, and increased co-morbidities in ageing populations. These now represent the largest burden of disease globally and make up 70% or more of the costs of health care in industrialised countries. Health systems in Western countries were largely designed for episodic and emergency care while these patients require long-term care, often over many years.  New services are needed and different approaches with more care and treatment provided in the community or at home and he greater involvement of patients themselves.  Moreover, there is an urgent need for a new emphasis on disease prevention and health promotion so that patients can remain as healthy as possible for as long as possible.

The problem is even more complex in developing countries. They are also affected by massive increase in non-communicable diseases while at the same time most of them suffer from continuing epidemics of infectious diseases as well as high levels of maternal morbidity and mortality and physical and mental trauma. Health services in much of southern Africa, for example, have to take account of the high levels of HIV/AIDS and the complications this causes in treatments for all other health conditions. Nevertheless, diabetes rates are rising faster there, albeit from a low base, than anywhere else in the world.

Turning the World Upside Down

High income industrialised societies can, however, learn a great deal from low and middle-income developing countries where people have far fewer resources but are able to develop new practices and implement new ideas without the vested interests and baggage of history that constrains innovation in richer countries. I explored this in “Turning the World Upside Down” where I described examples from Africa and Asia where people had developed very effective ways of engaging the community, supporting women, developing new roles for health workers in countries with few doctors and creating new business models designed to reach the poorest people.[ii]

Many of these innovations are precisely the sorts of things we need to understand in high income countries if we are to tackle non-communicable diseases effectively. There are already instances where low and middle-income countries have leapfrogged our development – in some aspects of telemedicine, for example and in the development of locally based community health workers. They can, of course, also learn from us and our experience, science and technology.  I argue that the future needs to be about co-development and mutual learning.

There is, however, a danger that as their resources increase, low and middle-income countries will follow too closely our development and create systems that are too dependent on hospitals and specialists precisely at the point when we are trying to move away from them. Many leaders are aware of this. I recall the South African Minister of Health telling me that we pay the people who try to prevent diabetes a little, people who treat diabetes more and the specialists who treat the complications of diabetes even more. Our priorities are turned upside down. He was trying to turn them the right way up.

The Social Determinants of Health

It is easy to see the importance of health promotion and disease prevention in low and middle-income countries and to recognise that this is not just about persuading people to adopt healthy life styles, important as that is.  Societal factors have an enormous impact on peoples’ ability to be healthy.[iii] The absence of health and safety legislation and adequate road traffic regulations, for example, poor employment practices and the lack of pollution controls all impact adversely on health. Stunting caused by malnutrition affects millions of children in Africa damaging both their mental and physical development.

In recent years governments have become more conscious of the social and wider determinants of wellness and the importance of health creating societies that enhance health not damage it.[iv] Recent actions in the UK, for example on tobacco control, traffic pollution and the use of salt and sugar, are welcome examples of government acting to provide the conditions in which citizens can live healthy lives.

The Changing Roles of Health Workers

The way in which health workers are educated, trained and deployed is already changing as new types of service are developed. There are virtual general practice (GP) surgeries in the UK, telephone and video-based consultations and community based services for many conditions that used to be exclusively provided in hospital. The biggest change we are beginning to see, however, is the development of nursing and the widening of the roles that nurses are enabled to play.

Recent years have seen, for example, the creation of nurse-led clinics, nurse practitioners trained as first responders to emergencies and nurses prescribing and undertaking procedures in many countries. It was only when nurses were allowed to initiate treatment with anti-retrovirals in South Africa that the HIV/AIDS epidemic began to be brought under control. In Holland an entirely nurse-led and nurse-based service has taken over large parts of the community and home-based care and is now being copied in other countries. In the US there are intensive care units run by nurses with doctors off-site and available to make decisions and support them via video and ‘phone. Meanwhile, countries as diverse as Germany, the Sudan, Pakistan and Singapore are investing in and developing their nurses.

There are several reasons for these developments, including improved education, better evidence about what nurses can do, the availability of nurses (there are more than 20 million and they make up half the health workforce globally), their cost relative to doctors and of course, the enabling impact of technology. However, I suspect the biggest underlying reason is that they are particularly well suited to the epidemiological and societal changes we are experiencing.

Caring for people with non-communicable diseases requires clinicians to take a holistic view of their needs. An elderly man with Parkinson’s Disease for example will need medication but may well also need help with eating or socialising or be enabled to live in a supportive environment.  He will also, no doubt, have views about what sort of care he wants, about the priority to be given to tackling his different symptoms and the trade-offs to be made in his care. Patients and their families and carers will need to be listened to and engaged.

Nurses are educated to have a bio-psycho-social-environmental view, considering all these aspects and “walking alongside” their patients. Other health professionals may also take this wider view, of course, but for nurses it is an essential part of their profession. Doctors, on the other hand, are generally educated to take a bio-medical view of health and it is this narrower view that pre-dominates in their practice and in health systems more generally.

Nurses provide continuity of care, are there when other health professionals are not, and are very often part of the community they serve. It is estimated that they provide more than 80% of the hands-on care provided by health professionals. This closeness to patients and the community also means that they are well-placed to work with individuals and communities on health promotion, disease prevention and improving health literacy. They understand the local culture and can influence local people better than more distant authority figures.

Taken together, these characteristics suggest that nurses will have an even bigger role to play in the future particularly in managing diseases, providing primary care and community services and in public health, prevention and promotion. ^[1]

The Vision and the Risks

This discussion starts to bring alive the new sort of health systems we can expect to see in the future. It will be much more community and home based.  Nurses and other non-medical professionals will play a wider role, as will patients and their carers and families. There will be greater emphasis on prevention, promotion and health literacy both within the health system and in other sectors such as education, employment and the environment, and this will be accompanied by political action from governments and activists. All of this will be enabled by technology and driven by increasing scientific knowledge.

In 2014 I chaired a Commission on the Future for Health In Portugal which concluded with the vision of “A transition from today’s hospital-centred and illness-based system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and health care. It will use the latest knowledge and technology and offer access to advice and high-quality services in homes and communities as well as in clinics and specialist centres.”[v]

The report went on to say that “This vision maintains the founding values of the SNS (the Portuguese national health service) and builds on the strengths of the current system, the skills of health professionals and the achievements of the past – but it demands new approaches, different infrastructure and a lower and more sustainable cost base.”

new approaches, different infrastructure and a lower and more sustainable cost base.

The Portuguese Government of the time accepted the vision we spelled out. This sort of vision is being articulated in many places around the world and some elements are starting to be put into practice. However, it is not yet happening at scale anywhere. It is noticeable that both businesses and governments tend to focus on possibilities of the technology with little if any emphasis on the human factors, cultural aspects and the development of health workers. Moreover, the emphasis remains firmly on health care rather than on improving health and preventing disease.

There are many reasons why there is such slow and incomplete progress being made. The first and most obvious is that this is a truly massive transformation and there are enormous implications for everything from regulation to professional education. There are very strong vested interests among service providers and the professions in maintaining the status quo. Moreover, there are huge sunk costs and, if the transition is to be managed smoothly, there is a need for the costly parallel running of the old and new systems while the transition is made. Making change at this scale is very difficult.

This transition is also politically very risky. It will take more than one political cycle and is not attractive to politicians who may find themselves running for election when there is the risk of greatest turmoil and, potentially, public opposition. They will also need to deal with many public concerns about, to take only two examples, the ethics of scientific developments such as cloning and the use of personal data. The latter made much worse by the behaviour of the internet and social media giants with their careless disregard of data security and seeming inability to control its abuse.

There are also risks inherent in the new science and technology itself. There is a danger of exaggerating the accuracy and scope of new medical tests and treatments or of misinterpreting their findings and the results. Most of us would probably think that health screening was undoubtedly a good thing yet there is continuing debate over whether even such well-established processes as breast screening, for example, do more harm by throwing up false positives than they do good. There has recently been advocacy for a new screening process for the early signs of dementia which sounds very good until you realise the accuracy is only 80%. How much harm is done to the many people who may receive false positives and have to consider whether, for example, they are still safe and legal to drive?

This is further complicated by the fact that health care is prone to market failure. There is an asymmetry of information between the providers of health care who are generally expert and knowledgeable and the consumers, who are not.  Moreover, people needing health care are almost always anxious, ill, confused or to some extent vulnerable when they need it and therefore open to suggestion and, in the worst cases, manipulation. Sadly, there are many examples of just this sort of abuse in countries around the world.

Traditionally, people have tried to deal with this sort of dilemma through regulation and by seeing doctors or health workers as the patient’s advocates and guardians, making or helping to make decisions on their behalf. In the last decade NICE, the National Institute for Health and Care Excellence, in the UK has produced guidance on the efficacy of therapies and on when they can be used with positive impact.

Underlying all this is a question of trust and whether the public believe the businesses with their new products, the government agencies like NICE designed to safeguard their interests and their own professional advisers and advocates. Recent controversies about vaccination in countries all around the world show that there is a significant minority of the public who do not trust any of them.

Given these risks it is perhaps not surprising therefore that we see only incremental progress being made towards this vision of a transformed health system. Digital health is not the panacea or silver bullet that it may at first appear. It does, however, hold the promise of great rewards for patients and populations and, if they get their strategies right, for businesses of many different sorts.

Potential Success Factors

Looking forward, successful implementation is likely to depend on three main factors. Firstly, how well it aligns the two meanings of the technological and the hands-on or people aspects. In practice, there has been too little attention paid to the human factors and transforming what health workers do – surprising in a sector where at least half the costs are in the people globally and 70% in high income countries.

Secondly, how much attention is given to prevention, promotion and tackling the wider determinants of health – from education to housing, employment and the environment.  There is no point in causing disease and then finding a smart way to treat it.

Thirdly, and underpinning both the other two, is the question of how governments, health workers and businesses can build trust with the public and patients. Here, I would suggest there is a particular role for nurses who, as already noted, are close to the communities they serve and in recent years have become the most trusted profession, overtaking doctors in the process.

Nigel Crisp

September 2018

References

^[1] It is against this background that I and colleagues established Nursing Now as a campaign to improve health globally by raising the profile and status of nurses. Launched in February 2018 it had local groups in more than 40 countries within 3 months, suggesting that it is an idea whose time has come.

[i] Mark Carney speaking at the Republic of Ireland’s Central Bank, Dublin on 14 September 2018 as reported in the Times, London, 15 September 2018 p4.
[ii] Crisp N: Turning the World Upside Down – the search for global health in the 21st century; CRC Press, London, 2010
[iii] World Health Organisation: Report of the Commission on the Social Determinants of Health; Geneva, 2008.
[iv] Crisp N, Stuckler D, Horton R, Adebowale V et all: Manifesto for a Healthy and Health Creating Society; The Lancet, London, October 7, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31801-3
[v] Calouste Gulbenkian Foundation: The Future for Health in Portugal; Lisbon, 2014