‘Water, water everywhere. Nor any drop to drink’ -The Rime of the Ancient Mariner (Samuel Taylor Coleridge, 1834).
We are facing an informational deluge in Medicine. The amount of healthcare, biomedical and social research data being collected doubles every 12-14 months and, in 2012, a Ponemon Institute study found that thirty percent of all the electronic data storage in the world was occupied by the healthcare industry. Our ability to structure, access, interpret and derive value from data is becoming increasingly more difficult. It is expanding exponentially in volume and also in complexity.
Electronic Healthcare Records (EHR), Picture Archiving and Communications Systems, Electronic Prescribing Platforms and Messaging protocols all contribute to the ocean of information through which users need to navigate. The move to digital has been rapid over the past decade and in U.S. hospitals, EHR adoption rates have gone from 10 to 90 percent in that time and the UK is rapidly catching up.
The need to gain efficiencies has partly been responsible for this digital evolution, though the promised land of fully integrated IT still seems achingly out of reach. While converting from paper-based records to digitised ones is underway, connecting inpatient systems to those in family practice or with other hospitals is far from being achieved. And where an EHR system at one practice cannot communicate with that at another, the likelihood of the clinical systems linking with the scheduling and billing, financial reporting and practice management software is even lower.
Both clinical and administrative data flow efficiencies are important, but it is equally vital that new healthcare delivery models evolve to accommodate the ever-increasing demand.
Telehealth and remote patient monitoring are not new concepts - in the 1970s, Kaiser Foundation International partnered up with Lockheed Missiles and Space Company to create a remote monitoring system capable of providing healthcare delivery.
There has been an enormous amount of technological progress since then.
High speed internet connections, wireless communication protocols and new legislation have all contributed to the increasing levels of adoption - (the American Recovery and Reinvestment Act (ARRA) of 2009 and the HITECH Act were two major pieces of legislation that brought forth a multitude of reforms and medical technology advancements). With these enablers, hundreds of start-ups and incumbents are now starting to offer remote medical services with the global telemedicine market valued at $38 billion in 2018 (and estimated to be $103.8 billion in 2024).
As all of these developments converge to present new opportunities, there are also new challenges. With distributed and democratised healthcare, the shift to patient-centric care is swiftly becoming the new norm. And as the old paternalism dissolves, governance structures need to adapt. New games require new rules and data flow regulation needs to be managed.
The closer the patient-owned data wave approaches shore, the more we see data inputs from a multitude of retail wearable devices too. Patients are not only using hospital-deployed telemetry devices but are now collecting health data independently. Whether from a Fitbit, Apple watch or Poonyah all-in-one device, hundreds of products now enable patients to capture their vitals anywhere and anytime.
The range of medical wearables in use are legion. From the in-utero foetus to the infirm elderly care-home resident, it is possible to monitor most aspects of an individual’s health.
Data for its own sake, however, does not really have much value. It is only when information and knowledge are derived from data that we start to gain actionable utility. The end users of this data vary enormously too.
While elite and hobbyist sports men and women, the military and extreme environment actors may have interest in fitness variables, the worried well and those managing chronic diseases may be interested in different parameters. Data for personal use has some value for individuals. The real benefits, however, occur when big data sets can be explored by others.
Research institutes and biopharmaceutical R&D labs might discover new therapies applying AI and advanced analytics, and governments and insurers may have greater clarity on disease prevalence and risk profiles.
There is of course great commercial interest too and the market is large. Remote patient monitoring and health trackers will generate $20 billion annually by 2023. Revenues aside, the potential cost savings from improved sickness prevention and reduced days in hospital may dwarf these predictions. Early warning scores and predictive analytics may fundamentally change the way patients are managed and as wearables become part of patients’ treatment plans, the data being generated will almost certainly influence the business models and potential revenues possible. Juniper Research suggests this will reach $855 million by 2023.
It would be bizarre if you were not excited by these possibilities. The FAMGA (Facebook, Amazon, Microsoft, Google and Apple) tech giants certainly are. Examples of some of their healthcare projects (owned or invested in) include:
- Radiology, Suicide prevention, addiction treatment, opioid misuse, hospital data research (Facebook)
- Medical supplies, cloud computing services, collaboration with Cerner, pharmacy retail, health benefits for employees (Berkshire Hathaway/JP Morgan partnership) and Alexa voice enabled services (Amazon)
- Healthcare, AI research facility, Cambridge (Microsoft)
- Verily, Calico, Deepmind, 23andme, Doctor on Demand, Oscar Health (Google)
- Health Records, devices (and telemedicine patent!) (Apple).
One could argue that these tech giants may well bring enormous innovation to healthcare. They certainly have the resources and penetration to affect billions of lives.
On the other hand, one might be concerned about the power of the oligopolies and the risks to privacy. Only 22% of Americans said that they trust Facebook with their personal information, far less than Amazon (49%), Google (41%), Microsoft (40%), and Apple (39%).
The dilemmas we face are not new. Personal liberties versus the benefit of the collective, intellectual property rights (and the derived dividends) versus the enhanced insights gained from open access.
Van Panhuis et. al. published a systematic review (Biomed Central, 2014) which identified twenty potential barriers to data sharing in public health – some technical and motivational others political, economic, ethical or legal – making it increasingly imperative that we find ways to overcome this.
It is unlikely that any single innovation will unlock the data potential. There are, however, some aspects where distributed ledgers may have an impact.The value proposition is well known – trusted value exchange brokered by network consensus, governed by smart contracts and incentivised through crypto-economics. Of course, this is largely theoretical at the moment. DLT solutions are immature, mostly untested and predominantly in the proof-of-concept phase.
A review by Cornelius Agbo and colleagues at the University of Ontario Institute of Technology concluded that further research is required to definitively prove the utility of blockchain in healthcare. That said, remote patient monitoring use-case studies using DLT are included in this piece of work and include at least seven papers where smart contracts or blockchain for end-to-end security and access controls were successfully deployed.
As the volume of data continues to swell, new models of sharing are becoming more critical. The potential value from doing so increases exponentially. Coopetition as a model is rapidly becoming a necessity, and DLT appears to be the best technological facilitator we currently have.
Technical solutions, however, cannot work in isolation. All sustainable change requires economic, political and cultural buy-in and these new collaboration models are a reasonable departure from the models of today. Nevertheless, there does seem to be a shift across the globe to a more connected society -a zeitgeist of positive impact over material gain and a preference for sharing and giving over owning and taking. Perhaps the blockchain is one enabler of this greater social movement.
