In late December 1516, the English lawyer, social philosopher, author, statesman and noted Renaissance humanist (and future catholic saint), Thomas More, published Utopia, a book about an ideal society on an imaginary island in an unknown place faraway across the seas. Even 500 years later it stirs debate as to whether this is some kind of comment or criticism of contemporary European society, blueprint for socialist philosophy, the first work of science fiction or more simply a clever farce. Or perhaps a combination, in some way, of all of these things.
In the 500 years since its publication Utopia has influenced everything from books, philosophies and political movements as varied as Daniel Defoe’s Robinson Crusoe, Mahatma Gandhi’s doctrine of passive resistance and the tech giants of Silicon Valley. Although More didn’t invent the concept of a perfect society, the term utopia has come to define it; interestingly the word translates from Greek to mean ‘no place’ or ‘nowhere’.
Technological Utopianism is the notion that advanced science and technology will allow ideal living standards to exist; enabling the ending of poverty, transformations in human nature brought about through empowered communication, the abolition of suffering and even the end of death. Medicine on the other hand has never really been as seduced by the idea of medical utopia, the ending of disease and abolition of death. Building a better world in healthcare often comes with significant challenges both ideological (how can we get high quality healthcare to as many people in the world as possible?) and practical (how can we utilise our resources to get the best treatment to the right person at the right time?). Technology can significantly improve these challenges but we are not building utopia, we are making small improvements everyday by trying and sometimes failing.
In June of last year the American Medical Association (AMA) CEO and Vice President James Madera MD addressed the AMA House of Delegates at the organisations annual conference on the subject of medical innovation and digital technologies (amongst other things, of course). What he said caused a stir amongst the many digital health evangelists online (of which I am one), especially as much of the 140-character synopsis simply stated he believed digital health was ‘snake oil’. Many of the people who share thousands of links a day on the latest application, tool or service that will ‘revolutionise’ medicine castigated him as a philistine unable to accept the inevitable disruption of healthcare. King Cnut commanding the ‘tsunami’ of digital technology not to break the shore of traditional medicine. Just as Cnut was misrepresented (he was actually demonstrating to his subjects how even a king has no power over nature), Mr Madera has also been taken out of context to serve a purpose for a well-meaning cause.
What Mr Madera called for at the AMA conference was that innovations in medicine must be “validated, evidence based, actionable and connected”. This is in my mind absolutely true and stand in contrast to the majority of PR launches for the latest digital health ‘breakthrough’, which don’t obviously tick any of these boxes.
I have spent the last 5 years in helping to build a company that’s primary focus is the design and development of technology that can be proven to improve clinical outcomes for patients and support healthcare professionals to improve the provision of care. It is the most exciting place to be, not just in healthcare but also in technology. However it is not easy and we have developed some guiding principles that have helped us in medical fields that range through asthma, pulmonary arterial hypertension, diabetes, HIV, transplantation, addiction and oncology. All these programmes utilised different technology and were trying to solve different problems, however these principles still held true for us:
Clinical significance. This is key for us. If something is not based on a deep understanding of the interventions required to improve outcomes and utilising validated instruments in order to measure the impact, it is a red flag with regard to the possible significance of the solution. This is just as important for the management of chronic disease as it is for the prevention of illness, much of the focus within the ‘wellness; space has been on unproven interventions based on non-scientific ‘proxy’ measures such as steps or calorific intake.
Built through partnership. Medicine, as with most things, works best when it is collaboration. If something is going to be clinically significant it needs to built in collaboration with practicing clinical expertise, clinical academia, patient advocacy, real patient target users and very often pharmaceutical companies. Indeed, digital health is an area where pharma can truly work in equal partnerships to drive innovation on an equal footing with key stakeholders. If projects do not contain multi collaborative stakeholders this is a sign there could be an issue.
Focussed on behaviour not technology. Advances in technology and its subsequent ubiquity, such as with the adoption of smartphones, enables us to reach and support people with their health in a way that was unimaginable 30 years ago. Add to this the rapid advancement of sensor technology and the broader connected health landscape, which have enabled us to measure blood pressure, body mass index, blood oxygen saturation (to name a few from live programmes) and may soon enable us to non invasively measure blood glucose and even emotional response.
However, what lies behind the majority of challenges in health is need to modify behaviour. The vast majority of decisions we make are not rational but driven by an emotional response. That is why we focus on behavioural psychology and it’s application in digital health design, integrating with people’s lives and life-style, supporting decisions in context of where they are and what they are doing and most importantly, providing the most value possible for the least amount of effort on behalf of the user-this is termed a lack of friction. If the objectives and the value are not predominately in favour of the user it is a warning that we could be on the wrong track.
Scalable. In simple terms we define scalability as the capacity for as many people as possible being able to use the technology we produce to improve patient outcomes and the provision of care. Scalability rests on a number of factors that within healthcare can be very complex and sometimes intractable.
Firstly there is the simple availability of the technology utilised with the target users. In many ways technology only becomes really useful in healthcare when it is boring technologically. It is only when a large percentage of the population have access to a technology that we can impact health on the scale required to make an impact.
The other key factor is the integration of health technology into the clinical workflow. There are many initiatives that although mean well and could have real value, are not practically usable in the real world healthcare setting. We always work with clinical practitioners to make sure that they can actually use the solution and that, in using it, we are improving efficiency and patient care, not making it more time consuming or complicated.
The final scalability challenge is interoperability: the capacity for disparate systems to work together and share data. This is a challenge within country geographies, let alone when scaling across global markets. We focus on symmetry of data between the user and the HCP. If we can build interoperability we do, however what is most important is that any new technology adds genuine value, when it does, people work to make it applicable to their healthcare setting.
We need to stop the hype surrounding digital health, we need less cheer-leaders and more ball-players. Instead we should focus on those people and initiatives that are practically making a difference to clinical outcomes for patients, with evidence behind their application. We are not chasing or proclaiming a health utopia, this will lead us nowhere, instead those of us practically working in digital health are lucky enough to be at one of the most exciting moments for both healthcare and technology-we should focus on delivering for both patients and HCP’s and bringing about the revolutionary changes we all hope for evidentially and without the hyberbole.
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