A Pharmacy Student's Perspective on Digital Health

What is Digital Health?

Digital health can be defined as the coming together of technology and healthcare. Applications include improving the efficiency of healthcare provision, sharing of information and achieving more personalised care.

In doing so, we are able to help address the challenges patients and healthcare professionals are faced with on a daily basis. Using both hardware and software information and communication technologies (wireless devices, telemedicine, medical imaging etc), digital health has the potential to completely transform the way patients engage with services and manage their health and wellbeing [1].

 “By 2020, it is hoped that a quarter of patients with long-term conditions such as hypertension, diabetes and cancer will be able to monitor their health remotely”

BBC News, 2016

The use of technology in healthcare has come a long way over the years - with computers first being used in the 1960s and GPs receiving direct funding from the Department of Health for digital systems in the 1980s. In 2002, Delivering 21st Century IT led to the creation of the National Programme for IT (NPfIT), later renamed as Connecting for Health. This organization aimed to create a single electronic care record (ECR) and develop an IT infrastructure across primary and secondary care for healthcare professionals. Another milestone was when the Secretary of State for Health in 2012, Jeremy Hunt, introduced new ideas to drive digital technology in healthcare. For instance, in 2013, he challenged the NHS to “go paperless” by 2018, and since April 2016, patients have had access to their full GP records through an online service [2].

Digital Health today…

Here’s a quick overview of some of the key innovations in digital health with some of my thoughts:

• mHealth (mobile health), works by collecting a patient’s data during their everyday life. This information is then either transmitted to a doctor directly, or stored in a database to monitor how the patient is responding to a treatment over a period of time. Clearly, the benefits of mHealth are “hard to overstate” providing doctors with the kind of insight that they would never be able to achieve through “traditional time slots and clinical evaluations” [6]. I can see, with all this data, doctors have a unique opportunity to observe how a patient reacts outside of a clinical environment, which would aid in recovery, treatment adherence and condition monitoring. It can even be configured to notify the patient and doctor in critical situations e.g. if blood pressure levels drop too low or rise too high, alerting them to seek medical attention, if required.

• Store-and-Forward Telemedicine - This involves first acquiring medical data, and then sharing this information (lab reports, medical imaging, videos etc.) with a doctor, radiologist, or a specialist at another location [3].

• Real-time Telemedicine - This form of telemedicine refers to the use of a special type of video conferencing software in order for patients and providers to hear and see each other. Some progress has also been made in the field of ‘telepharmacy’. Pharmacists have been able to provide drug therapy monitoring, patient counselling and have used videoconferencing “to enable prescriptions to be clinically checked at different departments by a pharmacist working in a single dispensary” [16].

• Remote Patient Monitoring - Also known as ‘telemonitoring’, this works similarly to mHealth - allowing healthcare professionals to monitor a patient’s vital signs and activities from a distance [3]. Often used for the management of high-risk patients, this type of telemedicine can help tackle ‘bed blocking’ – a huge problem in the NHS. Through Remote Patient Monitoring, patients can safely return to their own homes instead of staying in hospital and occupying space for longer than required [5].

• Genetics Database - This will provide clinicians with a huge database of information that can be used to overcome a number of challenges e.g. to determine the way that a disease affects different demographics or how a virus spreads in particular areas. It could even be used to help doctors establish the best possible treatment for a certain individual. This means, for instance, a patient of a particular age with a certain blood pressure can receive the treatment that is most suitable for them. It also means that when viral outbreaks occur, such as the Ebola crisis of 2014, “the genetics of the disease from the earliest patients can help prevent the disease spreading as rapidly in other areas of the population” [6]. This kind of genetic profiling of an individual “with respect to prediction of disease risk and drug response” is likely to have a significant impact on “understanding disease pathogenesis” and enabling “truly personalized therapy”. Treatment would involve prescribing “therapies specific to individual patients based on pharmacogenetic and pharmacogenomic information” [20]. With the advent of genetic medicine, pharmacists will need to keep “up to date with the latest scientific findings around emerging precision medicines, as well as educating patients on these drugs, including the risk of adverse events due to drug–drug interactions, polypharmacy and co-morbidities” [17].

• 3D Printing - Although in the healthcare arena this is currently limited to mostly just prosthetics, there is an argument that when the technology develops, 3D printing has almost endless possibilities. In the future, 3D printing may be able to “create organic matter” suggesting that it could create anything from new skin to fully formed organs that could be transplanted [6].

Issues surrounding Digital Health

Despite such innovations there are a number of challenges that come with digital health.

For one, many digital health products that demonstrate impressive results in clinical trials often fail to do so in the real world. As a result only a fraction of these products actually make it to the market. This is because digital health relies on engagement [7].

An article published in The New England Journal of Medicine (NEJM) Catalyst in July 2017 states that when it comes to digital health products, “patients need to be highly motivated to make behavioural changes”, arguing that they need to be “praised when they follow through and…[given] guidance when they slip up” [7]. Guidance can take the form of simply spending more time with patients, making shared decisions and optimising education around digital health with an overall emphasis on better communication [8]. Furthermore, clinical trials often also involve the use of a number of tools (e.g training, close monitoring, payments) in order to make sure that patients are using these technologies appropriately, most of which are never used in the real world. The article claims that digital health companies need to focus more on patient engagement in order to achieve success with these products in practice.

The Commonwealth Fund conducted a study in which they developed a criteria for evaluating the patient engagement of mobile apps and developed specific strategies to activate patients using these applications. Figure 1 shows how we can drive patient engagement [9].

Figure 1 - Strategies to activate patients using mobile applications

The Commonwealth Fund, February 2016

The main limitations with digital health today, according to a paediatric nurse-practitioner speaking in The Economist, include barriers to interacting with patients via phone, email or videoconferencing, failing to address the needs of the patient. For instance, taking such video-calls she “cannot look into children’s ears or listen to their chests”. Although this is currently a challenge with digital technology, the article argues that, as more sophisticated forms of diagnostics become more widely available remotely, more patients will be able to “receive hospital-quality care without leaving home”.

 Discussion

Although there are a few challenges with the use of technology in healthcare, I certainly feel the future with digital health is bright. Pharmacists in particular will be able to enhance patient experiences through the use of innovative digital health tools. A number of these innovations are lined up especially within the NHS.  In March 2017 an NHS Digital Academy is set to train and develop 300 digital leaders by 2021 [2]. Moreover, although the goal for paperless operation in all healthcare settings has now been extended to 2020, as stated in the NHS five year forward view, going paperless could potentially save the NHS millions of pounds, as well as creating a service that would be “more convenient for patients, and help doctors to provide faster diagnoses” [10]. In fact, reducing the “burdens of bureaucracy on clinicians” has been acknowledged as a key advantage of harnessing technology in healthcare [11].

In the US, doctors are said to be “willing” and patients “eager” as they have indicating an interest in one or more aspects of digital health [12]. Once again it seems to be very much about ‘engagement’ – if patients “want to access digital services” they “will be able to find providers” [12].

The importance of digital health in the pharmaceutical industry has also been discussed [13, 18, 19]. Digital health is a “strategic opportunity for pharmaceutical companies” and some of the forward-thinking companies are “now awakening to the opportunity for digital health to strengthen their businesses.” Using digital health technologies alone or in conjunction with medications, pharmaceutical companies can significantly improve outcomes. Novartis, for instance, has already proposed the idea of using “home-based telehealth remote patient monitoring with heart-failure medications.” This “digital-drug combo” can save unnecessary trips to the hospital, simply by monitoring patients’ weight gain and intervening early.

Conclusion

As a pharmacy student contemplating life as a qualified healthcare professional, I feel digital health is an area that can truly revolutionise the way we care for patients.

It feels we are just beginning to scratch the surface, with so much more room left for further innovations. The pharmacy profession, in particular, has the opportunity to grow significantly, especially in the community setting whereby pharmacists could use these tools to “extend their real-world patient relationships into the digital landscape” [15]. Moreover, deploying these digital health tools in a community pharmacy, an incredibly competitive marketplace, could also help drive both prescription sales and pharmacy efficiencies [14]. Pharmacists can also “be the hub that both supports and enables patients to be more engaged” which would in turn help healthcare providers be more “proactive and prepared” [14].

Bibliography

 (1)   Honeyman, M. Dunn, P. McKenna, H. (2016). A Digital NHS? An introduction to the digital agenda and plans for implementation. The King’s Fund. Pg. 1, 3. Available from: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/A_digital_NHS_Kings_Fund_Sep_2016.pdf. [Accessed on: 20th July 2017]

(2)   The King’s Fund. (2017). Digital health policy - a timeline. Available from: https://www.kingsfund.org.uk/topics/technology-and-data/digital-timeline. [Accessed on: 20th July 2017]

(3)   Chiron Health. (2017). Types of Telemedicine. Available from: https://chironhealth.com/definitive-guide-to-telemedicine/about-telemedicine/types-of-telemedicine/. [Accessed on: 20th July 2017]

(4)   The Economist. (2017). How hospitals could be rebuilt, better than before. Available from: https://www.economist.com/news/international/21720278-technology-could-revolutionise-way-they-work-how-hospitals-could-be-rebuilt-better. [Accessed on: 20th July 2017]

(5)   The Telegraph. (2016). 21st-century healthcare: how technology is revolutionising the National Health Service. Available from: http://www.telegraph.co.uk/connect/small-business/business-networks/bt/technology-in-the-nhs/. [Accessed on: 20th July 2017]

(6)   Digital Health Age. (2015). How technology is changing the healthcare landscape. Available from: http://digitalhealthage.com/how-technology-is-changing-the-healthcare-landscape/. [Accessed: 20th July 2017]

(7)   Joseph C. Kvedar, MD & Alexander L. Fogel, MBA. (2017). Why Real-World Results Are So Challenging for Digital Health. NEJM Catalyst. Available from: http://catalyst.nejm.org/real-world-results-digital-health-products/. [Accessed on: 20th July 2017]

(8)   Kevin G. Volpp, MD, PhD & Namita S. Mohta, MD. (2016). Patient Engagement Survey: Improved Engagement Leads to Better Outcomes, but Better Tools Are Needed. Available from: http://catalyst.nejm.org/patient-engagement-report-improved-engagement-leads-better-outcomes-better-tools-needed/. [Accessed on: 20th July 2017]

(9)   Karandeep Singh, M.D. , David Bates, M.D., Kaitlin Drouin, Lisa P. Newmark, Ronen Rozenblum, Jaeho Lee, Adam Landman, Erika Pabo, Elissa V. Klinger. (2016). Developing a Framework for Evaluating the Patient Engagement, Quality, and Safety of Mobile Health Applications. The Commonwealth Fund. Available from: http://www.commonwealthfund.org/publications/issue-briefs/2016/feb/evaluating-mobile-health-apps. [Accessed on: 20th July 2017]

(10) BBC News. (2016). NHS to get £4bn in drive for 'paperless' health service. Available from: http://www.bbc.co.uk/news/health-35514382. [Accessed on: 20th July 2017]

(11) Sarah Bloch-Budzier. (2016). NHS using Google technology to treat patients. Available from: http://www.bbc.co.uk/news/health-38055509. [Accessed on: 20th July 2017]

(12) Mayernick, L. (2017). Digital Health in a Time of Transformation: Technology Changes Everything. Available from: https://marumatchbox.com/blog/digital-health-time-transformation-technology-changes-everything/. [Accessed: 20th July 2017]

(13) Fried, N. (2017). Pharmaceutical companies and digital health startups: It’s time to get together. Available from: http://www.mobihealthnews.com/content/pharmaceutical-companies-and-digital-health-startups-it%E2%80%99s-time-get-together. [Accessed on: 20th July 2017]

(14) Ng, V. (2014). Digital health coach: the evolving role of pharmacists. Available from: https://www.longwoods.com/articles/images/TELUS%20Sante_v2.pdf. [Accessed on: 20th July 2017]

(15) Nosta, J. (2013). Digital Health And The Pharmacy: A Prescription For Success. Available from: https://www.forbes.com/sites/johnnosta/2013/08/20/digital-health-and-the-pharmacy-a-prescription-for-success/#53a54851597c. [Accessed on: 20th July 2017]

(16) King, L S. (2014). Remote pharmacy: it’s closer than you think. The Pharmaceutical Journal. Available from: http://www.pharmaceutical-journal.com/remote-pharmacy-its-closer-than-you-think/20065564.article. [Accessed on: 20th July 2017]

(17) Robinson, L. (2017). Q&A: Pharmacists must be ready to provide precision medicines. The Pharmaceutical Journal. Available from: http://www.pharmaceutical-journal.com/opinion/qa/qa-pharmacists-must-be-ready-to-provide-precision-medicines/20203118.article. [Accessed on: 20th July 2017]

(18) Champagne, D, Hung, A, Leclerc, O. (2015). How pharma can win in a digital world. Available from: http://www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/how-pharma-can-win-in-a-digital-world. [Accessed on: 20th July 2017]

(19) CBInsights. (2017). Strong Medicine: Where Big Pharma Is Placing Bets In Digital Health In One Timeline. Available from: https://www.cbinsights.com/research/pharma-digital-health-startup-investments-timeline/. [Accessed on: 20th July 2017]

(20) Nair, S. (2010). Personalized medicine: Striding from genes to medicines. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043364/. [Accessed on 22nd August 2017]