“Aunty Kathy, what’s the wifi code?” demands my 11 year old niece the minute she bounces through the door, even before, “hello”. It’s the first question most children (and many adults) ask on arrival anywhere, and I have learnt to keep said code close at hand. Digital technology pervades every aspect of modern life, work and leisure increasingly takes place in ‘The Cloud’. Many appear to spend more time in the virtual rather than the real world. So, as everyday life and modes of communication move from human, analogue interchanges, to digital, how is this changing things in the arena of health and wellbeing?
Knowledge and take up of the opportunities to use digital technologies in the health and wellbeing space does seem to be gathering momentum. How many guys do you know who have been proudly showing off their Christmas gift of a new Apple Watch that, as well as telling the time and enabling facetime, also checks their heart rate and exercise stats. What about the competitive ‘yummy-mummy’ with her fitbit counting steps and weightwatchers phone app; not to mention the cycling ‘weekend warrior’ tracking progress and competing via Strava on their ipad and phones?
Product marketers are also positive and claim that, coupled with appropriate health education, health tech can encourage greater confidence in self-management, improved adherence to medications and diet, a healthier lifestyle, and more personalised medication and treatment. This is reflected in the rapidly increasing development of new innovations and devices, with an astonishing 165,000 health apps now available.
The question is – Will this momentum contribute significantly and equitably across our society; with citizens embracing ever more sophisticated technology, enabling greater ownership and control of our own health and wellbeing, and changing behaviours to achieve improved health outcomes for all?
In seeking to answer this lets first look at current attitudes to health technology.
The second Health Tech & You State of the Nation results survey, conducted by YouGov in September 2015 confirmed increasing adoption of health technology, highlighting devices such as pedometers and smartphone apps to manage and maintain personal health and wellbeing. Interesting generational differences were found between attitudes to, and the adoption of, types of health tech. Younger people seem keener to embrace big data and demonstrate a belief that health tech can help with the management of long-term conditions (especially obesity, diabetes, cancer and heart disease). The older generations [more specific?, over 55?] are the ones with more of a focus and interest in monitoring devices
our health and wellbeing, reflecting proactive desires for informative, functional and interactive apps, according to a 2015 survey, by Push Doctor; The most common types of health applications in use are: exercise monitoring (22.8%); BMI measurement (17%); heart rate monitoring (16.9%); diet / calorie counting (15.2%); sleep quality monitoring (12.9%); and social media symptom sharing (5.1%). In the US, 79% of people are willing to use a wearable device to manage their health . Specific usage areas included: tracking physical activity (52%); tracking symptoms (45%); managing a personal health issue or condition (43%); tracking sleep patterns (41%); and tracking diet/nutrition (39%).
The same survey asked how respondents felt about the increased availability of health advice and health monitoring tools. 71% felt "positive about using technology this way to better understand their bodies" and believe it helps them to be more aware and in control of their health. On the other hand, nearly a third of people (29.1%) reported some degree of concern (e.g. “becoming too worried about my well-being”). In a recent US survey, the most common motivators for using an app varied across health conditions. More than two thirds (63%) of Americans with gastrointestinal conditions reported that they would use a health app to track diet and nutrition; among obese or overweight consumers, a similar proportion (61%) would use one to communicate with a doctor; half (50%) of those with pulmonary conditions for medication reminders; and just over half (52%) of those with cardiovascular issues to track sleeping patterns.
Secondly, what about evidence of benefits realised from using personalised digital technology and services in a health setting?
A growing body of research suggesting that people who have health issues and enter the health and care system as patients, when provided with capacity to manage their own health, are more likely to adopt healthy behaviours, with better clinical outcomes and lower rates of hospitalisation . The King’s Fund refers to such patients as ‘activated’, and has defined a scale to measure a patient’s level of activation, ranging from “Level 1 – starting to take a role” through to “Level 4 – maintaining behaviours”.
A report by McKinsey commissioned to model the potential of digitally-enabled processes, transparency and participation in the NHS in 2014, identified a range of quantified improvements feasible through “behaviour tracking apps” that would lead to improvements in the delivery of integrated care and screening. McKinsey reported that “as people’s uptake of digital channels increases, we expect to see greater impact from such newer approaches, as well as greater integration into comprehensive web-based self-help support platforms linking individual lifestyle information with patient records, facilitated transactions such as appointment booking”.
Evidence of actual take up and benefits realisation is available from a range of patient focused, digitally available services, examples include:
SMS reminders: now widely used by health service providers, have been relatively widely studied show impact may be comparable to other interventions. For example: SMS reminders as part of a smoking cessation programme were reported to have 9% 52-week quit rates compared to 4% with over-the-counter nicotine replacement therapy and 1% with simple GP advice text messaging service KickButs has been shown to be successful with smoking; and a 2011 controlled study with 6,000 participants showed significant impact smoking quit rates at 6 months from SMS reminders for smokers -10.7% quit rate for intervention vs. 4.9% for the control group.
Digital services for patients to self-manage chronic conditions: The NHS Simple Telehealth Florence programme in Stoke has been successful in the management of hypertension . Where the patient monitors their blood pressure from home, texting results to Florence (an automated triage service), who provides instant advice and instructions in line with clinical pathways and protocols. Evaluation concluded that it “was found to be an effective and acceptable way of quickly gaining control of blood pressure (BP) in hypertensive individuals — even among those who had been previously difficult to engage”.
Remote weight management programmes: have most success where interventions combine digital and traditional approaches. Often in the form of lifestyle support programmes, they combine risk assessment, setting personal goals, creation of action plans, targeted information and support in implementing these plans, often with motivation support from peers and/or incentives programmes.
Online Mental Health Therapy and Support Services: where health tech can also help overcome patients' reluctance to seek help because of stigma or shame. Examples include:
• Cognitive Behaviour Therapy (CBT) delivered via digital teleconsultation, evidence shows impact comparable to face-to-face therapy; Ieso Digital Health , an online CBT service, is allowing therapists and patients to work together collaboratively during real-time appointments in a ‘secure portal therapy room’. If patients have questions or require added support between consultations, the therapist can be available ‘at the touch of a button’. Available across 26 NHS clinical commissioning groups, providers claim it shows how effective (technology) can be for treating mild to severe mental health issues at a ‘fraction of the cost of traditional therapy services’.
• The Big White Wall is an online platform that offers users an opportunity to record their mood, chat with other users and get in touch with their clinicians via a variety of digital channels. Evidence has shown its online therapy service achieves a 58 per cent recovery rate (against an average from other therapy services of 46 per cent and a national target of 50 per cent).
Digital Services in Primary care - In London, the Hurley Group has developed a digital suite of online services which allows patients to: source frontline peer and specialist advice; check symptoms; access self-help content; and be sign-posted to other services. With their GP systems supplier EMIS, they have developed an eConsult service in which patients can submit condition-based questionnaires to their own GP (on the 100 most common presenting conditions). The service also allows GPs to conduct virtual online consultations with patients. The evaluation report on the pilot project has shown that one half of patients who consulted online were managed remotely, with fewer GP appointments and shorter waiting times. The service has now been extended to cover 1M patients.
Digital Service in NHS Acute care – Examples include:
• Poole Hospital NHS Foundation Trust has been working on an epilepsy networks project to record and track patient-related information. The service uses apps, wearables and shared health records to collect data from epileptics to better predict seizures and match back to medication information. The service provides “social sensing” from family and close friends to collect social data from those around the patient to enrich the life-logging dataset. The aim of the project is for earlier, tailored interventions and more empowered patients.
• South Devon NHS Healthcare Foundation Trust introduced a tailored health coaching service from MSD Closercare to 100 patients with heart failure . The academic results concluded that the vast majority of patients increased their ability to self-care by at least one level as measured by the King’s Fund measures of patient activation .
At a national level the government has set out the contribution digital can make to delivering better levels of care and helping the NHS’ long term sustainability. The concept of personalised healthcare where individuals are active as ‘co-producers’ of their health and wellbeing, supported by digital technology is enshrined in current health policy, planning guidelines and priorities. This is driven by identified potential for efficiency savings from activating patients to take greater ownership and control of their health and wellbeing and shifting key transactions, such as booking GP appointments and ordering repeat prescriptions online. Savings from such approaches were estimated at over £90m in the period 2012-2020 and the McKinsey review mentioned above estimated that the developments it identified, combined with other digital technologies, could lead to a staggering annual net benefit of £1.3-£2.5bn.
What are the main barriers to widespread adoption that we need to consider?
The survey and research results to date indicate that, as with most new technical capabilities, there are a number of barriers to universal demand, consumer appetite and effective adoption and exploitation. If, as a society we believe that these technologies can help all of us to live healthier, active lives then we need to understand the barriers to widespread take-up.
Such barriers include the potential for dis-benefit, often arising from poor understanding and inappropriate use of the technologies. For some people there is real fear in the concept of wearable tech or having technology installed in their home raising surveillance and privacy concerns. Gathering and communicating evidence of tangible benefits is key to tackling this, as is effective communication about confidentiality safeguards. We also need to develop approaches that address the rapid pace of the developing digital world, requiring more agile and formative research to measure the effectiveness of the technology in terms of health and well-being improvements. Alongside this, the evidence highlighted above points to the importance of suitable education and training alongside the provision of the technology products in order to gain the benefits of use and manage the potential down-side, such as raising anxiety about one’s health.
Another issue to address is that of motivation to use, and continue to use, available technology to assist in adopting healthier lifestyles. The evidence indicates that there are definite groups who already have a raised interest and awareness and who are adopting the technology to follow healthier lifestyles: from parents managing and coordinating the health and well-being of their families (e.g. social media such as mum’snet where parents share experience and concerns, the digital red book); individuals spending their leisure time pursuing exercise and competitive sport; to people activated by health screening who wish to address increased risks identified. But for many people it isn’t until they themselves, or a close friend or relative, are actually ill, that they really consider how they can make the effort to invest in maintaining their own health and wellbeing. In common with any marketing and communications campaign, efforts to raise awareness, demand and ultimately effective adoption need to use the increasing body of evidence and insight to target these different audiences in ways most meaningful to them.
The shift towards more consumer-oriented personalised care making effective use of the increasing digitisation of our everyday lives and the increasingly available applications and services increasingly requires a fundamental re-design of existing healthcare structures and IT infrastructures to ensure full benefits can be achieved. So far health information systems and technology have been developed around services and organisations, they are ‘closed’ systems considered to ‘belong’ to the NHS organisations and professionals. To achieve a digitally enabled system, with the person truly at the centre, requires a new approach supported by policy, industry and demanded by citizens themselves; in line with Sir Michael Marmot’s assertion that we need to “to create the conditions for people to take control over their own lives”.
This needs to be linked with increased focus on health promotion through applying research in behavioural economics, which has the potential to improve people's quality of life. Exploiting new ways to promote healthy behaviours through digital enablement, for example in leveraging predictive analytics applied to complex data for improved decision making in the management of a chronic disease. As Sir Muir Gray says, “knowledge is the best enemy of disease”.
The ‘Health Tech & You’ partnership between AXA PPP, 2020 Health and the Design Museum was formed in 2014 to identify and promote consumer digital health technology and innovators that enable self-care and condition management. Entries for the 2016 Awards are open until Feb 1st and more details can be found here.