Digital technology: A cultural shift in healthcare

Do you remember the primary function of a wristwatch? It is a timepiece, which gives you the time of the day and in some cases date as well. A wristwatch, worn by individuals to keep track of time, might also serve as a fashion accessory, but that's about it! It's been that way for hundreds of years (Queen Elizabeth I of England had one).

Now there is a paradigm shift underway in the functions of a wristwatch. For the emerging generation, they still keep track of time, but also track our activity, heart rate, sleeping pattern—if you are willing to pay a little more, it will manage your emails and social media. We are moving beyond the era of smartphones, we are entering an era of the smartwatches.

Disruptive technology has brought incredible changes in our daily life across the world. Not so long ago we had to queue in banks carrying an account book to access our accounts—difficult for generation Y in many countries to imagine. Now we access our accounts, manage transactions, pay bills and transfer funds between countries from our palms, perhaps, from our smartwatches. However, to find out whether our blood sugar level is getting better or worse (diabetes patients), we likely have to travel several miles, still wait in a queue in a waiting room for an indeterminate time, sit in front of a clinician, go find a pharmacist and queue again, (repeat process later if the test-kits are out of stock), return all the way home, and somewhere along the line, pay a bunch of money. There has been a modest trickle of digital technology into public health, often almost incidental, such as mobile phone applications, but the digital revolution has largely passed by, particularly at the primary health level. Healthcare has been plodding while the emerging generation has been sprinting, embracing a transformation in much of the rest of life—through social media, entertainment, mobile cash transfer, the transportation sector through ride share programmes like Uber.

This is set to change. Technology will make healthcare far more accessible, participatory and less patriarchal. In traditional medicine the patients are absent in decision-making, the entire onus is on the healthcare practitioners for both curative and preventive healthcare. Especially for non-communicable diseases (NCDs), patients' participation should be key to manage or cure the illness. After all, they live with the problem day and night. According to World Health Organization (WHO) the global burden of disease is shifting from infectious diseases to non-communicable diseases with chronic conditions. The statistics published in June 2018, showed that NCDs kill 41 million people each year, which is equivalent to 71 percent of all deaths globally. Tobacco use, unhealthy diet, lack of physical activities, use of alcohol increases the risk of NCDs. Digital health proffers an opportunity for patients to take control of their own health.

Two of the greatest obstacles to high-quality primary healthcare in low-income countries are a lack of skilled health workers and the limited access to reliable, actionable health information. Even where clinicians exist with sufficient skills, health information systems are rarely organised to collate and deliver feedback on health trends to the provider. Medical records have minimal content and may be difficult to access, and diagnostic results may arrive too late to influence therapy. Communication gaps between health providers caring for the same patient result in fractured care, wasting time and money and risking outcomes. Barriers, such as limited capacity to collect and use data or accountability for performance, can severely limit the ability of health workers to integrate local epidemiology and real-time data on diseases. We need to break down the barriers that separate patients from their health records, limit the quality of clinician decision-making, and access to essential health products. We need to digitise health.

Fascinating insights into the future can be seen in promising pilots, such as, the WISH Foundation in India which has developed systems in public clinics in Rajasthan, India where tele-consultations between village dwellers and city-based medical specialists are opening direct access to high-level care near to their home. Treatment is dispensed immediately from a modified electronic dispensing machine in the same clinic, based on a bar-coded prescription transmitted remotely by the specialist. Further south, in Karnataka, Healthcube is integrating dozens of sensors and tests into a portable electronic box that provides high-quality patient diagnosis and monitoring for a host of medical conditions. Their aim is to make healthcare delivery hassle-free and accessible. Closer to home, icddr,b in Dhaka is collaborating with international partners in the US and Cambodia to develop a system for recognising patients from birth to old-age with a smartphone or tablet, which could allow immediate access to medical records for the patient and clinician.

Healthcare delivery is ripe for such innovations. According to Bangladesh Telecommunication Regulatory Commission, there are about 147 million mobile phone subscribers (Jan 2018 data). So, 147 million subscribers could receive directly their medical records and test results without returning to the clinic, secured by technology such as fingerprint or face recognition, blockchain and other data management systems. This will transform medical care in low-income countries into a data-driven, logical, and optimised decision-making process. Incorporating real-time, epidemiologic data with patient history, diagnostic results and latest evidence-based clinical data, medication resistance, and supply chain issues into treatment plans for presenting patients makes these computerised models dynamic and widely accessible, responsive to changing conditions, unlike current static, paper-based systems. The proliferation of mobile phones and increased access to the internet means that data can continuously flow back and forth between systems and users. This dynamic approach can be thought of as a kind of personalised, public health medicine, where the local epidemiologic milieu and treatment possibilities inform management, and, therefore improve outcomes. Availability of mobile phone has made tracking certain services, such as ante-natal care, pre-natal care, expanded programme of immunisation much easier. We perhaps need to explore how else technology can be used for preventive care, diagnostics, therapeutics and comprehensive disease management.

Digital revolution in healthcare is now feasible, the required components exists, we just need to connect the dots. There are pilot examples in neighbouring countries and the African continent of successful IT enabled healthcare on a local scale—such as teleconsultation, automated drug dispensing. The implementation needs to be carried out ethically and with caution—it requires a collaborative effort by government and the private health sector, and some new and innovative ways of collaborative thinking (for the health sphere). Also, the trust between healthcare professionals and patients need to be maintained. Any glitch in that process will defeat the purpose of accessible healthcare. The genesis of this is with us, so now is the time to shape it, to ensure that technology is introduced in an equitable way, accessible for all and aimed at a people-centred model for healthcare. It must be a tool to narrow the gaps in healthcare, not the domain of a select few, as many recent advances in health technology have become.

Dr David Bell is an expert in Malaria, Infectious Disease Epidemiology, Consultant in Global Heath and Health Technologies Innovation. Anindita Roy is a Public Health Specialist, working with an international organisation in Geneva, Switzerland.