Digital Health White Paper .pdf

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Digital
Health:
The Road Toward
Revolution.

Digital Health:
The Road Toward Revolution.



Where to begin?..............................................................................................................4
Where next? ................................................................................................................... 5
The challenges................................................................................................................ 7
Long term conditions are draining too many resources.................................................................................................................... 7
Software ........................................................................................................................................................................................... 8
The Cultural & Communication Challenge .....................................................................................................................................13
Ensuring standards.........................................................................................................................................................................13

Conclusions .................................................................................................................. 14
Case studies..................................................................................................................18
1. National Programme for IT (NPfIT)............................................................................................................................................. 18
2. Care.data.................................................................................................................................................................................... 21
3. Cambridge University Hospitals (CUH) ......................................................................................................................................22

2

3

Where to begin?
Our health services are in crisis. They are by no means bad, quite the opposite, they are amongst the finest in the world.
The problem is that, like many of the world’s health services, they are operating in an unsustainable way - like planes
that are running out of runway.
Unless you have been living under a rock, this is not exactly news. This crisis has been in the making for several
decades. Yet, the healthcare revolution that will deliver us from this emergency and transform our health services into
vehicles that are built to withstand the pressures of a rapidly evolving world, has thus far eluded us.
However, we are running out of time. Successive failures have left our health services strained and in a state of inertia.
Subsequently, we are witnessing a steady stream of related scandals, declining levels of accessibility, ever growing
treatment costs and a bitter internal disputes, the repercussions of which are sure to be long lasting.
The tragedy is, it does not have to be this bad.
The NHS alone employs 1.6m people, putting it amongst the
largest employers in the world. Regardless their role, seniority or
speciality, the vast majority of these people have something in
common - they share a deep desire to improve our health services
and preserve them for generations to come. Indeed, the continued
ability of many services to function to a high standard is testament
to this fact.
This quantity of human resource and concurrent desire is more
than enough to make a difference, but we need to rethink the way
that we use technology to empower this would be task force for
change.

NHS PERSONNEL GROWTH
2004 - 2014

+32,467

Doctors

+18,432

Nurses

Firstly, we must do more to engage with a much broader audience
on the subject of healthcare and the role of technology within it. As
such, some of the topics covered in this paper will be well known to
many members of our intended audience, but unknown to others. If
you are one of the former: please know, that needlessly going
over old ground is not our objective. However, a general lack of
understanding surrounding these issues outside of the medical
community is in itself a large part of the challenge we face in
healthcare. Failure to readdress this imbalance is likely to result in
further failure. Therefore, where we cover information that is well
understood and widely accepted, we will do so concisely, adding
context where necessary, in such a way that brings new audiences
quickly up to speed.
Subsequently, we need to make practical recommendations about the way forward with regard to the implementation of
technology in healthcare. Boldly authoritative though this may sound, we have arrived at a juncture where this is
absolutely necessary. Inertia is now one of the most immediate and dangerous threats to health services. Many of the
challenges that we must overcome are widely agreed upon and as such, we must now turn the full force of our attention
to the implementation of solutions.
Whilst the nuances of each challenge are broad and varied, there is a common vein running throughout the equally
broad array of proposed solutions. That is, that we must empower clinicians to deliver better, more preventative
treatment at the expense of less resource. The best way to do this is to put highly powerful, yet affordable tools directly
into the hands of healthcare professionals, without disrupting their existing workflows, and let them get on with their jobs.
The simplicity of this philosophy is radical, but we argue that if implemented with the right amounts of creativity and
ingenuity, it presents the greatest opportunity to deliver scalable results at the speed we need them.
The resources necessary to sustain the current approaches to digitising health services are not available and often the
results yielded do not warrant such massive expenditure of already scarce funds (see Cambridge University Hospitals
4

case study p.22. The situation with regard to funding and other resources is unlikely to change in the short to medium
term future, especially given renewed uncertainty relating global economic stability. Moreover, there is growing
consensus surrounding the idea that traditional approaches are helping to further entrench outdated ideas and practices,
rather than facilitating a radical reiteration of healthcare delivery. If conventional approaches drain limited resources,
entrench inflexibility, deliver limited results and rely on technologies that are rapidly becoming irrelevant, can we justify
remaining attached to them? The answer is “no”.

Where next?
So who and what will shape the
future? An analysis of market trends
holds answers. 2011 marked the
beginning of an investment bonanza in
digital health that has not yet showed
signs of letting up. Conclusive market
size data on the more heterogeneous
global and European digital health
investment spaces is not widely
available, however, in the more the
mature US market, early stage
companies attracted venture funding of
up to $4.3bn in 2014 and $4.5bn in
2015 (Rock Health, Digital Health
Funding: 2015 Year in Review).

2012
UK Population
63.7m

2020
UK Population
67.13m

2030
UK Population
71.04m

UK POPULATION GROWTH

This activity is indicative of innovators and entrepreneurs aligning with one another in response to converging factors that
have created both a major challenge and subsequent opportunity.

NHS EXPENDITURE

£64.2

£116.6

billion

billion

2003

2014

NHS net expenditure has increased from £64.173 billion in 2003/04 to £113.300bn in 2014/15. Planned expenditure for 2015/16 is £116.574bn

Health expenditure per capita in England has risen from £1,841 in 2009/10 to £1,994 in 2013/14

5

Converging factors:
1. Current models of healthcare are unsustainably expensive and cannot cope with demand
2. Challenges presented by demographic changes require healthcare systems to adapt
3. The healthcare space remains under-penetrated by technology due to:
- Clinical adversity to risk
- Political wrangling
- The ghosts of failures
- Concerns over privacy
4. The potentially global impact of new healthcare technologies has been recognised:
- The potential impact of mobile technology on healthcare delivery in the developing world and under-serviced
areas of the developed world has been acknowledged
- Technology has become socially embedded with the birth of the first generation of digital natives
5.Frameworks now exist that enable connectivity and collaboration between a vast array of differently sized and focused
entities
- Entrepreneurs and investors have identified the commercial opportunity created by failing healthcare systems
and the potential application of new technologies
- Policy makers and institutions have recognised the problem-solving potential of innovator/entrepreneur
partnerships
Common sense would dictate that the convergence of these factors represents the ideal conditions for transformational
change. Yet, services remain in crisis and increasingly dependent on the sheer grit and determination on their human
elements for survival. This begs the question: what obstacles remain and how can they be overcome?

NHS EXPENDITURE 2

£1.2bn per annum
Litigation costs

70% of total NHS budget
Long term conditions
£1.2bn per annum spent on litigation fees – an estimated 50% of this is spent on determining blame due to lack of proper audit trails

70% of the total NHS budget is spent on treating long term illness

6

The challenges
Long term conditions are draining too many resources
In the UK alone long term conditions affect in excess of 40%
of the population (approx. 20 million people). The cost of
caring for this section of the population accounted for as
much as 70% of the NHS’s £133bn budget for 2014/2015
(insert source). Each of these patient costs on average
£1000 per year, increasing to £3000 and £8000 per year in
the event that second and third long-term conditions are
developed (insert source). This phenomenon is known as the
“comorbidity of disease” and is occurring with increasing
frequency (insert source).
The alarming rise in the prevalence of conditions such as
dementia and diabetes fundamentally threatens the future of
traditional healthcare models. Action is urgently needed to
reduce the costs of these models and to promote a
proactive approaches to personal wellbeing and disease
prevention. Mobile, wearable and implant technologies will
be instrumental in facilitating this transition and a handful of
innovators operating within this area of the digital healthcare
are thankfully making strides in terms of market traction and
the adoption of their technologies.
The promise of these technologies and the size of the
market at stake has prompted forays into healthcare by
technology giants such as Apple and Google. In 2015 Apple
launched HealthKit and ResearchKit in a bid to supercharge
medical research and the large volumes of data it requires.
The initiative will potentially revolutionise the speed and
scale of research by allowing researchers to access
unprecedented volumes of anonymised data collected by
iPhones worldwide. Google’s play, which inadvertently
began with the launch of Google Glass in 2013,
encompasses this field and much more, including
implantable devices, open source medical record storage
and artificial intelligence. In many ways this buildup is in
response to the pioneering work of lesser known innovators,
but their involvement in the space is now a significant
driving force in itself.

INNOVATOR PROFILE

ABOUT:
Web and mobile based cognitive
behavioural therapy (CBT)
applications that support patients
undergoing treatment for dementia,
Parkinson’s, diabetes, heart
disease and cancer.
The applications use reminders,
journals, educational modules that
allow patients to live more
independent lives, improve
adherence to treatment and
communicate realtime information
to clinicians.
FUNDING:
2012: (A)
2015: (B)

£500,000

£2m

EXAMPLE CUSTOMERS:
Kings College Healthcare NHS Trust


These promising developments have largely been possible due to the ability of innovators businesses to access, or sell
to consumers directly. They are part of a wider trend towards a healthcare ecosystem that is centred around the
individual, rather than well known care environments, such as GP’s practices and hospitals. There simply isn’t the
resources to continue to conventionally treat patients with long-term health conditions. We, as individuals, must start to
accept greater responsibility for our health and disease prevention. Indeed, the most visionary healthcare technologists
are already preoccupying themselves with a future in which hospitals do not exist. Where innovations like nano-robotics,
swarms of robots smaller than a single grain of sand, will allow for the treatment of patients wherever they may be. For
some, acknowledging that we may witness the application of this technology within our lifetime would be laughable.
Perhaps this is because for many, “healthcare” still involves passing the time in waiting rooms and clinicians that are
hamstrung by pagers, fax machines and a lack of critical information. However, innovations that until recently were
considered to be nothing but science-fiction, such as prosthetic limbs that can be controlled through thought, are now
very real and rapidly approaching readiness for wide scale usage. In the short to medium term innovations that are
7

currently widely available, such as those facilitated by mobile
technology, must be used to help relieve conventional
services and prevent their collapse. The consequences of
failing to offset the latter eventuality do not bear thinking
about.

INNOVATOR PROFILE

HARK

Software
In many ways healthcare has not seen the benefits of rapid
advances in software development in the same way as other
sectors. As we have already highlighted, adversity to risk,
past failures and concerns over data security have prevented
progress. As such, common software solutions, like Patient
Administration Systems (PAS) and Electronic Health Records
(EHRs or EMRs), lag behind market leading technology
standards and are at best, viewed as a necessary evil that
deliver very little value for users. The user interfaces of
market leading softwares depicted in sources 1 and 2 (p.11).
begin to explain the source of these sentiments.
State led attempts to bring health services up to speed, that
predate these systems have failed, as exemplified by the
calamitous National Programme for IT (See NPfIT Case
Study p.18). New problems have been created by the
proliferation of largely American EHR systems that has
followed. These systems are prohibitively expensive and
where they have been implemented they have been
responsible for moderate to severe service disruption (See
Cambridge University Hospital Case Study p.22). Research
shows that technology deployments of this nature are prone
to failure and deliver less. According to a McKinsey/Oxford
study half of IT projects with budgets of over $15 million
dollars run 45% over budget, are 7% behind schedule and
deliver 56% less functionality than predicted. That means
that, at least half the time, achieving at least $15 million in
benefits, requires spending $59 million (McKinsey-Oxford:
Reference class forecasting for IT projects).

ABOUT:
HARK is a clinical task management
application that is using
artificial intelligence to begin
trying to automate assigning and
prioritisation of clinical tasks.
HARK is currently being piloted
across the Imperial College NHS
Trust where it was developed and
was acquired by Google DeepMind in
early 2016.
Google DeepMind has recently made
headlines after striking a deal
with The Royal free NHS Trust that
will give them access to over 1m
patient records. The records will
be used to attempt to use Google
DeepMinds’s AI to preempt the
deterioration of patients
suffering from kidney conditions.
EXAMPLE CUSTOMERS:
Imperial College NHS Trust

The Royal free NHS Trust


Scarcity of funds and scepticism regarding their usefulness,
means that only 1 in 3 UK hospitals currently has an EHR.
On balance, their risk-reward trade-off does not warrant prioritising their continued deployment as a means of digitising
services. Encouragingly, alternatives to the types of system depicted in sourceS 1 and 2 (p.11). are beginning to emerge.

NHS PROCEDURES
In 2013/14 there were 44
per cent more operations
completed by the NHS
compared to 2003/04,
with an increase from
6.712m to 9.672m

125m hospital
episodes per year

44% More operations
125m hospital care episodes

8

It is becoming increasingly apparent that the primary drivers of meaningful change will be lean innovator businesses
working collaboratively to address technology pain-points in healthcare ecosystems. Each seeking to definitively resolve
individual components of overarching challenges. The key areas where these nascent businesses are already
demonstrating competitive advantage are:


Product design



Size and flexibility



Attitudes towards data security and sharing

UK PRIVATE HEALTH

9341

Private hospital
beds in the U.K.

60%

Estimated
average
occupancy

3.2m

Estimated
admissions p/a

9341 beds in the UK

Estimated 60% occupancy

Estimated 3.2m admissions per annum

9


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