Digital health success hinges on four principles

This is the third article in a series on the making of the digital health revolution. IN 2012, Dr Eric Topol published The creative destruction of medicine: how the digital revolution will create better health care. Dr Topol’s book is excellent in describing the problems with the current health care industry. At the end of the book he observes:

“Not a single aspect of health and medicine today will ultimately be spared or unaffected in some way. Doctors, hospitals, the life science industry, government, and its regulatory bodies: all are subject to radical transformation.”

Dr Topol’s book was written over a decade after a report from the Committee on Quality Health Care in America, which was part of the Institute of Medicine – Crossing the quality chasm: a new health system for the 21st century. Why are we still far from seeing mainstream uptake of digital health? The major reasons are that it is unclear whether the benefits of digital health technologies outweigh the risks and costs. There is also the fact that digital health involves a shift in mindset about how medicine should be practised. And we don’t have a consensus among clinicians, technologists and lawmakers of what the future should be, other than it must be different from what we have today. The current approach       In applying IT to health care a common assumption is that the application of technology that was designed to solve other problems through standardisation, industrialisation and production lines will work with health care. What is happening in some cases, electronic health records being an obvious example, is that technology-driven solutions cause more problems than they solve. There are an increasing number of reports that doctors are spending considerable time on data entry resulting in dissatisfaction and sometimes burnout. Many digital health initiatives today focus on symptom-driven, statistical, pattern-matching, correlation and risk reduction approaches. The transformation of health care requires a radical change to this approach to make medicine more personalised to the individual patient. The future paradigm The advancement of personalised medicine is a priority of governments and research institutions around the world, and rightly so given the impact that it could have on individual health and wellbeing. Personalised medicine is concerned with understanding the uniqueness of individuals, not just from assessing their DNA but their lifetime experiences, their behaviour, and their interactions with their environment, and diagnosing and treating patients by identifying causes and effects and treating the cause. In order to shift towards personalised medicine four things are needed:

• the acquisition of more and better data from the patient at the time and point of care;
• diagnostic tools and models that understand and interpret these data;
• treatment that addresses the cause of the problem; and
• a health care system that efficiently utilises this radically different approach to clinical medicine.

Real advances will not come from automating what is done today, but from a deeper understanding of how to identify the key characteristics of a person, their condition as presented at the point of care, and individually tailored treatment plans that are constantly monitored and adapted as the patient adapts. An illustration of the complexity of understanding and treating the unique systems of the individual is the example of neurogastroenterology. Medical science is discovering that the human digestive tract has a nervous system second only to that of the brain. There are also biological sensors and actuators that control the complex behaviour of digestion, absorption and waste disposal. Fully understanding this subsystem of human biology will require engagement with those more familiar with industrial automation and control systems. Achieving a good understanding is made more complex because there is no definitive design; it is often self-healing and is constantly interacting with external influences. Neurogastroenterology is only one area where the study of dynamic systems and control theory are essential to the transformation of health care. The personalised medicine movement explores individualised health from various perspectives. One such perspective is that of pharmacogenomics, which looks at how our genes affect our reaction to particular medications. The United States Food and Drug Administration recently approved a direct-to-consumer pharmacogenomic test, offered by company 23andMe. The limitation at present is that tests such as these are still far from being relied upon in clinical practice:

“Eric Topol, a geneticist at the Scripps Research Institute, points out that the genome variants they are analyzing are very limited. It’s simply too early. A review published by the American Psychiatric Association task force concludes that while initial data on the association of genetics and drugs has been promising, there’s not enough evidence to justify the widespread use of pharmacogenetic tests”.

The Verge 23andMe’s genetic test for how you’ll react to medication is ahead of its time

Other advances in the field of personalised medicine include epigenomics, which seeks to understand the “on” and “off” switches of our genes, how these switches are altered by our environments, and the ways in which genetic instructions are used by cells when these changes arise.

“Until recently, scientists thought that human diseases were caused mainly by changes in DNA sequence, infectious agents such as bacteria and viruses, or environmental agents. Now, however, researchers have demonstrated that changes in the epigenome also can cause, or result from, disease. Epigenomics, thus, has become a vital part of efforts to better understand the human body and to improve human health. Epigenomic maps may someday enable doctors to determine an individual's health status and tailor a patient’s response to therapies.”

National Human Genome Research Institute Epigenomics

A direct-to-consumer epigenomic test is currently offered through the company Chronomics. However, the test is limited to assessing biological age, smoke exposure and metabolic state. The exposome is another field of enquiry looking at how our environment influences our health. The exposome focuses on how the totality of our environment from conception onwards affects our internal environment. Digital health technologies can serve an important role in this field:

“New tools and technologies that can be applied to address these challenges include exposure biomarker technologies, geographical mapping and remote sensing technologies, smartphone applications and personal exposure sensors, and high-throughput molecular ‘omics’ techniques”

BMJ Thorax The exposome: a new paradigm to study the impact of environment on health

Other areas that will have implications for personalised medicine include transcriptomics, proteomics, phenomics, microbiomics and metabolomics. The challenge of change While personalised medicine is still considered the future paradigm, there is a range of digital health technologies that are already being implemented today. Some physicians might be telling patients about an application that tracks their adherence to medications, or options for continuous glucose monitoring, or tracking of a patient’s electrocardiogram with the use of a wearable device. Other physicians may see it as being too early to support such recommendations. In some hospitals you will find uses of artificial intelligence to check for errors in radiology results, remote robotic surgery, 3D printing, uses of telehealth technologies to connect rural and remote patients and for specialist assessment of patients on their way to the emergency room and once onsite. Incremental improvements in health care can deliver only limited benefits. Change in the digital health environment will happen slowly – people require time to adapt and adopt. It is highly likely that the old and the new will coexist for a significant time. Forced change towards digital health uses will not work; the result will be resistance and apathy. There is an opportunity for the leadership in this space to work towards understanding where the consensus lies on foundational tenets for a digital health school of thought. This, alongside further developments in science and technology, will provide the foundations for change. Importantly, we need to ensure that the shift towards digital health adds value to our society by helping us to achieve optimal health and wellbeing without giving up on other essential rights. To do so, it is necessary that the digital health school of thought is founded on principles of human rights, clinical and societal benefit, as well as risk and harm reduction. Bianca Phillips is a Victorian academic lawyer conducting medical law research. She completed her Master of Laws at the University of Melbourne with her thesis on telemedicine, and is currently completing a doctoral thesis on the law making of the digital health revolution. She has authored articles on the digitisation of medicine in both legal and medical publications. She can be found on Twitter @biancarphillips. Dr Bernard Robertson-Dunn trained as an electronic and automation engineer, has a PhD in modelling the electrical activity in the human small intestine and has had over 40 years modelling, architecting and designing large scale information systems, mostly in government environments. He is chair of the Health Committee of the Australian Privacy Foundation.     The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.