How will digital healthcare shape future care delivery and design ?

Prof Jeremy Wyatt Leadership Chair in eHealth Research

Clinical advisor on new technology, Royal College of Physicians

Agenda • What is digital healthcare ? • Some examples • Why digital healthcare ? • Where will care be delivered in future, and what

will happen there ? – Care outside hospital – Care in hospitals – The role of clinical research organisations

• How to judge if this is useful ? • Conclusions

For public: � Trust-marked reference sources � Cancer etc. support forums � Online personal electronic health records � Telehealth to support self care in long term

conditions � Cyber doctor

For health services: � eLearning � Transcription of dictated reports � Remote reporting of X rays, pathology slides � Remote control of surgical robots

What is digital healthcare

“Redesigned services supported by appropriate digital technologies”

Instant messaging triage by NHS Direct nurse

Devices to support digital healthcare

Helping Hand medicine reminder www.medicom.com

Ambient orb to monitor health status www.ambient.com

Diabetes monitor & insulin pump

Second Life & serious games

Health Info Island - UNC Chapel Hill & Cleveland Public Library

Not a new idea, in fact…

Why digital healthcare ?

Old model of care Focus on acute conditions, reactive management Hospital centred, disjointed episodes Doctor dependent Patient as passive recipient; self care infrequent Information & Communications Technology (ICT) used rarely Technology dominates

New model Focus on long term conditions, prevention & continuing care Integrated with people’s lives in homes & communities Team based, shared record Patient as partner; self care encouraged & supported Dependent on ICT & devices

Clinical needs dominate

Health care professionals may only interact with people with a chronic disease for a few hours a year… the rest of the time patients care for themselves… ££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££££

Access to health professionals

Source: NHS Policy Unit. United Kingdom figures.

Demand for care

Labour supply

Demographic challenges to NHS capacity

Questions an architect might ask

Who is the client: NHS, local govt (Manchester); CIC / SE; commercial (Circle Hinchinbrooke); person with LTC eg. home dialysis

What does the client want / need ? What activities must the space support ? How to know if it’s successful ?

Home / community care

Active homes • Sensors to monitor activities of daily living • Self monitoring medicine cabinet • Reminders to eat, throw away time-expired food… • RITA – avatar for people with dementia / frail elderly alone • Charging zones for wearables, smart phones, measurement

devices • Home robotics – lifting, stairs, bath, butler robot ? • Central locking, smart environmental control (Nest)

Implanted CardioMEMS sensor & transmitter in distal branch of descending PA

External device sending data to home hub; on screen questions and chart

Telehealth devices

Review of 46 trials in heart failure – mortality

Work of Dr Shiva Sathanandam

A future virtual health scenario Mrs Smith has high blood pressure and wakes with a headache. She worries that her implanted drug reservoir may be empty. Her ambient health orb is a reassuring green, so she turns to her video wall and asks “Cyberdoc, how is my blood pressure recently?”

The voice responds “Your drug reservoir needs a refill in 3 weeks but blood pressure readings are under control recently and normal today. Your blood sugar sensor shows normal readings too. Do you have some symptoms you want to discuss?”

Meanwhile Mrs Smith’s wall graphs her recent blood pressure and lists the 20 most common symptoms in people of her age group locally.

She responds, “No, don’t worry. Remind me to book my refill in two weeks, please.” Wyatt & Sullivan, BMJ 2005

Some issues

• Privacy in your own home ? • Connecting in real world to supplement virtual • Using tech to enable:

– friends & family to connect & participate in care – elderly contribution to society

• What does a buggy-friendly neighbourhood look like ? Glide-in cinemas / pubs / supermarkets ?

Community health hub • Analogies: rural telehubs; office space by the hour • More likely now councils taking increased role, ageing

population • Could house telepresence, haemodialysis,

chemotherapy infusion equipment

Not this…

On the road… ubiquitous healthcare

• Connected car • ECG sensors in seat back • Support for self management in diabetes,

asthma ?

Hospital care

Trial of teledermatology to prevent GP referrals

With Depts. of Medical Informatics and Primary Care, AMC Amsterdam

Closing the clinics ?

A new kind of workforce ?

• More junior staff supported by decision support systems, protocols

• Telepresence robots • Domestic / delivery

robots

What must we do in real world ?

• History taking (tele-presence ?) • Clinical examination, palpation (kiosk with haptics ?) • Psychotherapy (computer based behaviour therapy) • Taking blood etc. specimens (blood / saliva self

testing, lab on chip) • Invasive procedures, surgery (kiosk with robot?)

The potential of home based self management in LTCs

1. Agree therapeutic objectives 2. Provide education about the early signs of

deterioration 3. Elicit their own warning signs 4. Capture disease activity information 5. Give people their own information in usable form 6. Support adherence with drugs, appointments 7. Provide a safe envelope – and appropriate actions

when patient moves outside it

• (Wyatt & Wyatt, in preparation)

Some implications

• Hospitals get more specialist • Extensive use of VC facilities + data analytics • “Hospital discharge” is not about leaving the

building – RCP Future Hospital Commission report

Research centres: potential influence of citizen science

and patient controlled research ?

Citizen Science – CRUK Cell slider

• Your Contribution Matters • 2331103 images already

analysed • Join thousands of others

giving time to Cell Slider and become part of our worldwide collective.

• Each and every click adds to our totaliser above. You can make a real difference.

30/24

Crowd sourcing: potholes & cyclists

http://thepotholegardener.com/page/2/

www.potholes.co.uk – funded by Warranties direct

Asthmopolis

• Photo of airbus A380

Quantified Self studies

• QS: 28 founder members in SF 2008, 5524 in 42 groups early 2012

• Butter Mind study – RCT with 45 people, showed that eating 60g of butter / day improved speed of calculation. Methods unclear, no controlling for IQ / education etc. Reported in blog 2010

• Blueberry study – running since 1999, hundreds of participants, said to show 1% increase in online word recall exercises. Pub online / conf posters.

34/23

Summary - benefits of digital healthcare

• Allows patients and carers to do more • Responsive to user needs:

– “Disintermediation” – talk direct to specialist – Delivery anywhere (mHealth), anytime (global) – Mass customisation – the long tail

• Greater patient control, eg. over data (Mydex) • Better data improves quality, research • Access to a wider market – health tourism • Lower cost of delivery (?)

Financial benefits

£8.60

£5.00

£2.83

£0.15 £0£1£2£3£4£5£6£7£8£9

£10

Face to face Letter Telephone Digital

Cost

in £

per

enc

ount

er

Mean public sector cost per completed encounter across 120 councils

Source: Cabinet Office Digital efficiency report, 2013

We can fly airplanes remotely – but should we ?

Holistic health service ?

• Risk of a “Great Revulsion” (Muir Gray), eg GM foods • In Cheltenham people already spend as much on

complementary therapies as NHS spends on community services

• Those who can, might opt for old fashioned, face-to-face, holistic care

APEASE criteria for success in HC

Affordability Practicality Effective, cost effective Acceptable Safety, side effects Equity

Source: Michie et al. The Behaviour change wheel, 2015: 22

Some conclusions

• Clients for health architecture will become more diverse

• Healthcare will become (much ?) less centralised in hospitals

• The type of activities carried out in hospitals will change; some staff may even work from home

• Homes will need to adapt, too • Community health hubs to support people with

long term conditions