ESC's Prof Martin Cowie: 5 Questions On Digital Health

Siobhan Harris

Disclosures

September 05, 2018

Digital health is an umbrella term for a whole range of different technologies ranging from electronic prescriptions and electronic medical records, to remote monitoring, wearable sensors, and the use of big data.

The crux of digital health is using ICT to improve health or health care systems. It's used to help patients, conduct research, and track diseases. It also has the potential to save the NHS money.

There are challenges. The rapid pace at which new digital technologies are moving can be difficult for regulatory bodies and organisations to react to.

Martin Cowie is professor of cardiology at Imperial College London and chair of the European Society of Cardiology's (ESC) new digital health committee.

Medscape UK asked him about the significance and challenges of digital health.

Q&A

Medscape UK: How do you see your new role and why is the ESC focusing on digital health?

Prof Cowie: Digital is all around us, and at last it is having an impact on the healthcare sector. Often healthcare professionals are seen by policy makers as rather resistant to change and somewhat 'old fashioned' in their approaches to technology, but this is partly driven by unfamiliarity, security in the way we do things now, and also for the need for robust evidence before we change practice and reorganise complex services.

The ESC has been aware of the digital disruption in healthcare for some years, and had published a short position statement on this in the EHJ [European Heart Journal] in 2016. But in 2018 it decided to set up a Digital Health Committee to help co-ordinate its activities, and that of the Associations, in this space. This includes education, advocacy at the policy level, and research.

You will notice a raft of policy documents in the coming months, much more educational material on the escardio.org website, and specific areas within its conferences on all things digital. A good example was the Digital Area at ESC 2018 in Munich in August 2018: a continuous track of presentations and discussions on all things digital: always crowded and often tweeted about using hashtag #ESCdigital, and viewable all year round on the ESC 360 platform on escardio.org.

Medscape UK: What is the importance of wearables and remote monitoring? How can data protection and confidentiality be assured?

Prof Cowie:  Data security is a big issue, and rarely out of the news. Health data is particularly sensitive and regulations are strict, but policy makers are keen that this regulation does not stifle innovation and the use of information and communication technology to improve the efficiency and experience of healthcare.

Data leaks from remote monitoring technologies are exceptionally rare, provided people do not share passwords, and adhere to good practice guidelines.

There is a whole range of remote monitoring technologies from wearables (such as FitBit™, or AppleWatch™, or T-shirts that can record ECGs, such as CardioSkin™), to stand alone systems that wirelessly connect a weighing scale and a sphygmomanometer or hand-held ECG to an app or bedside unit that integrates this with symptom questions, to high-technology implantable devices (such as a CRT or ICD device or a pressure monitoring device such as CardioMEMS™).

The issue is not with the reliability of the technology – it is with how one integrates these data flows into practice in a way that is manageable and leads to improved decision making and outcome for patients, rather than just a massive extra amount of work for the healthcare team.

We have learned a lot from randomised trials over the past 15 years: not every patient needs such monitoring, but when targeted and integrated into a responsive decision making process these technologies can improve outcome and the experience of care. But a blind belief in 'all monitoring must be better than usual care' is naïve – and not likely to be funded by the healthcare system or insurance companies.

Medscape UK: Has the NHS got the budget to fund new devices and digital technologies? Does there need to be medical validation of new technologies to justify cost?

Prof Cowie:  Across the world, regulators and reimbursement authorities are struggling with how best to assess the value of a bewildering array of new technologies. By the time an assessment is finished the technology has evolved and policy makers are not enthusiastic about 'clunky' processes that discourage entrepreneurs and the new digital economy.

My impression is that a proportionate assessment process will develop, depending on the likely risks of any new technology or approach to care. But before funding is likely to emerge to support technology, some evidence of meaningful impact will be required. Tech companies realise this now, and can see that to have meaningful adoption healthcare professionals do require evidence, so that professional guidelines can grade the evidence base and make recommendations. The examples of technology that have taken off (such as Kardia™ for smartphone or watch based lead 1 ECG recording) show that evidence is needed.

In the NHS in England, a new tariff was introduced for innovative technologies, including at least one app for patients with chronic lung disease, and Kardia, and this has really helped adoption in primary care. Ultimately, unless technology is only going to be a luxury consumer item, the healthcare systems will have to be convinced of benefit – but ways of speeding up assessments and using 'real world data' are being considered to ensure our patients can gain access to valuable developments more quickly (and that they are protected from technology that turns out merely to be a gimmick).

Medscape UK: How will digital health change the role of doctors and specialists? Will some need extra training, or convincing?

Prof Cowie:  Already, digital technology is changing the way healthcare professionals interact with each other, and with patients. E-mail consultations or Skype-style consultations are increasingly common between professionals and with patients. Expertise is beginning to come to the patient, rather than the patient always having to seek out the expertise and come to a hospital or clinic at the convenience of the doctor.

In a real sense, people can have access to expertise on the global scale rather than being confined to the local hospital.

Image technology is a particularly good example of this already: images can be obtained and transmitted anywhere in the world, and interpretation can now be aided by artificial intelligence. Data collection can occur at the patient’s home every day, so when a doctor reviews the situation the data that is used to make decisions can be from non-traditional sources, and collected over much longer periods.

This of course has its challenges, as well as its opportunities, and navigating this area is not always straightforward. That is why the ESC is particularly keen to make sure its educational programme supports cardiologists in these new areas.

Medscape UK: Is the current system set up to react to such a fast changing area?

Prof Cowie: Our society is now always 'on', and the old model of very occasional interpretation of information collected at one face-to-face visit to a clinic is changing rapidly. Reimbursement lags very far behind innovation, and the evidence base is often slow to develop, so the incentives for redesign in clinical practice may be few. Policy makers want to see a faster speed of innovation and 'modernisation' of healthcare processes, and digital is part of this.

It is difficult to predict the future, but to my mind we will undoubtedly have a blurring of the boundaries between traditional healthcare and general health and lifestyle consumer issues, less siloed approaches, and a public that expects easier access, and at their convenience, to better decision making based on more information.

In turn, we may expect the healthcare system to push back to patients some aspects of their management: they can use technologies to support their own decision making around their chronic conditions, and they will only need to access the expensive healthcare professional and system when this is needed.

Some use the term 'democratisation' of healthcare: this may be an exaggeration, but undoubtedly things are likely to change, and to change rapidly.

Exciting but challenging times to be a cardiologist.

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