Healthcare innovations - outside the hospital

29th April, 2013 by Anonymous

Technology is taking healthcare into the community and closer to home, saving valuable resources, reports Jon Turney.

Your imaginary medical drama, like mine, probably begins one of two ways. There's an emergency call, blue lights and sirens, and a frantic dash to hospital. Or a bored receptionist ushers you toward the consulting room with a routine: "The doctor will see you now."

This is healthcare, old style. You go where the doctors are, either by appointment, or when you suddenly have no choice. The systems we have built on that assumption aren't going to stop any time soon, but they are under increasing strain. Populations are ageing, and costs rising. Health inequalities, whether measured across region or class in one country or across the globe, are stubbornly persistent.

Relieving the strain will need new approaches, from health professionals, governments, brands and businesses – but technology could be the key enabler. Until now, medical technologies (more drugs, more tests) have generally increased costs. But information and communication technologies which offer more personal solutions might prove the exception. They could even speed a reorientation of the whole system. Paul Grundy, Global Director of Healthcare Transformation for IBM, predicts "a profound change" in how health solutions are going to be delivered. He talks of shifting medical practice away from "an episode of care" towards management of health across populations, made possible by "the patient-centred medical home". He doesn't mean a 'care home' of the sort you visit when something's up: he means everyone in their own home.

Such a home would include some version of the 'bathroom GP' envisaged in a report published by Which? in January. Today's house may have bathroom scales linked wirelessly to a smartphone app. But come 2030, it could have sensors and microanalysers which monitor stool and urine samples for indicators of liver and kidney function, glucose levels, and viruses. The data is combined with read-outs of body temperature, heart rate, sleep patterns, calories used in exercise, all from discreet miniature body sensors, and analysed against the background of each individual's health records, perhaps including their genetic scan and family history.

Since, by 2030, everything is connected to everything else, the results can be displayed in the bathroom, or on your mobile phone. Anything out of the ordinary can also be relayed to the GP's surgery, without that tedious visit. A virtual consultation may follow, or the system may just repeat, say, the dietary advice you haven't quite been following – perhaps with a few new recipes and a shopping list to encourage better eating.

If this is the direction, how far down the road are we, and what will need to change? The basic technology for the tests already exists. Taking it to scale and linking the different elements together – at an affordable price – is probably only a matter of time. How they will fit into the complexities of healthcare systems is much harder to fathom.

Some of the trends forcing change come from our success in combating infectious diseases, changing patterns of illness. Rachel Maguire, who works on the future of hospitals at the California-based Institute for the Future, points out that more people now have a chronic disease, dealt with not by cure, but through long-term management. "With the burden shifting to account for an increased number of chronic conditions (especially now that many view HIV, assuming there is access to drugs, as a chronic condition), our systems will need to be redesigned to provide almost constant, or at least consistent, care to treat such illnesses, including mental health conditions, more effectively", she says.

Others wonder how well existing systems can promote such a shift. "What's needed is radical transformation", says Gemma Adams, a Principal Sustainability Advisor specialising in innovation and behaviour change at Forum for the Future. "Ultimately, we need a health service that avoids and reverses illnesses before they become serious, rather than focusing on urgent treatments. However, it's difficult to talk about this because the idea of anything but continuity and stability is alarming. The impetus for this kind of change almost definitely won't come from inside health services such as the [UK's] NHS."

Impetus comes from marketers selling smart phone apps

Some impetus comes from eager marketers trying to sell thousands of smart phone apps – which more people are buying. Internet giant CISCO Systems estimates there were 44 million worldwide downloads of personal health apps in 2012, and this will rise to 140 million by 2016. At the moment, most of these offer dietary advice and exercise regimes, as opposed to broader health monitoring. In the pipeline are apps that turn your phone into a portable electrocardiogram to monitor heart disease, and the likes of SkinVision, which will upload a photo of a mole on your skin for automated analysis. Users get reassurance if the algorithm judges the mole benign, and a message to visit the doctor if it looks suspect. Ancillary products for smart phones are also under development. For example, if you want to pee on a chip connected to your phone to check if you have a sexually transmitted disease, sparing you an embarrassing conversation at the clinic, a team at St George's Hospital in London is working on it.

More generally, a host of mobile phone apps, with names like LifeWatch or Doc@home, offer to help people monitor their health or lifestyle, or get access to medical advice. And there seems willingness to use them. An international survey, published in March 2013 by CISCO, found that about 40 % of people would be interested in receiving recommendations about doctors, hospitals or medication through mobile devices. At the moment, around a quarter of people with health care apps on their mobiles use them for chronic disease management, and around the same proportion get health-related reminders on their phone or tablet.

Shiny gadgets are all very well, but they'll never be the whole answer as 'stand-alones'. There is already evidence of the benefits that incorporating them into healthcare can bring to patients, and plans to build on this. The Department of Health in England, for one, wants to incorporate 'telehealth' into the NHS. It ran a controlled trial of remote health aids from 2008 to 2011, which involved 6,000 patients in 288 general practices. Different aids were used in different places, but all were chosen to help patients already diagnosed with diabetes, heart failure or chronic lung disease. Results published in the British Medical Journal in 2012 showed that the patients using devices at home to help monitor their condition had 20% fewer emergency admissions and, impressively, a 45% difference in mortality over 12 months, compared with the control group. The Department has launched the 'Three million lives' initiative to bring such technologies to more people with long-term health conditions or care needs.

The UK trial did not demonstrate any major cost savings. However, other studies have shown reductions in cost. Analysis of a heart patients' programme in Boston – which adopted home monitoring of weight, heart rate, pulse and blood pressure, and transmitted the data daily to cardiac nurses – noted a 50% reduction in hospital readmissions for heart failure patients, and savings of millions of dollars.

Good news for existing health systems, but mobile technology also shows promise in places where healthcare for most people falls far short of US or European standards – facilitating tasks such as collecting public health data, monitoring vaccination campaigns, or reminding patients to take medication. A well-known pioneer is ChildCount+, led by Matt Berg of Columbia University's Earth Institute, which uses phones to monitor pregnant mothers and young children in rural villages. It has been adapted to suit local goals, such as to prevent mother-child transmission of HIV in Kenya and Ghana: simple SMS reminders were sent to community health workers, who then passed on clinic appointment alerts to expectant mothers. Other applications include tracking pneumococcal vaccination in Kenya.

This kind of thing does seem to get results. A MedicMobile project, run by an organisation launched by Stanford physician Nadim Mahmud, found immunisation coverage among children in one neighbourhood in India increased by 20% when mothers were prompted by an SMS reminder to get the vaccination. More sophisticated devices will help gather information from patients – and could speed diagnosis. The Bill and Melinda Gates Foundation is supporting 'point of care diagnostics'.

Star Trek-style tricorders aren't on the horizon yet, but a health worker could soon have a hand-held device which can identify pathogenic organisms like those causing tuberculosis or HIV. Such testing kits, if they stand up to trials, will generate results on the spot in minutes, instead of sending samples to a distant laboratory where they join a queue for processing.

In countries which benefit from more developed health systems, flexible medical technology could be offered by intermediaries outside the hospital, lowering costs. Will we see people pop into their pharmacy and come out with an app? Andrew Bonser of Boots does not rule it out. In future, he suggests a transfer of care away from hospitals towards the high street. "Much of what you have to go to the doctor for now could be done in the community pharmacy", he says. Boots has already launched a Type 2 diabetes risk assessment service with Diabetes UK. Although this screening system uses an online tool, it is offered in the pharmacy, and illustrates how access can aid prevention.

For Anthony Townsend of the Institute for the Future, personal and environmental sensors are potentially a crucial part of a larger shift in urban planning, providing the data needed to ensure cities are healthier places to live and work. The city of Rio de Janeiro has presented its plans for integrated healthcare to the Living Labs Global Award 'Cities Pilot the Future' programme, which aims to discover and implement the most promising solutions to pressing social and urban challenges. Rio has been working on data collection to become a 'smart city' in preparation for the 2016 Olympic Games, and is looking for ways to enhance quality of life by integrating social support and health systems with mobility and other network services. Proposals include SMS-based information on alternatives to drugs, early detection of public-health risks, such as pollution hotspots, and remote mobile image-based diagnostics, such as teledermatology.

The ultimate goal – for megacities like Rio and rural villages alike – is to integrate preventative health, treatment and care into daily life, relieving the strain on hospitals and clinics by enabling communities and individuals to keep a check on their wellbeing and take simple actions to improve it. When patients do need to see a doctor, the queue should be shorter, and they should have a lot more information about what ails them.

Seeing the body for its parts

Take kidney or liver disease. Often these are caused by the presence of toxins in the body, and could best be treated in the wider context of the individual's lifestyle and diet – but medical solutions tend focus on the organ itself. As Forum for the Future's Gemma Adams points out: "Hospital treatments are geared towards slowing down or dealing with the symptoms of an illness even when it's still possibly reversible, because acute care specialists aren't qualified and can't refer people for life-style type interventions."

Public health initiatives and community services are starting to interconnect in more sophisticated ways. For example, liver specialist Sir Ian Gilmore set up the Alcohol Health Alliance UK in 2007 to increase awareness of unhealthy alcohol use and its ramifications on health and society.

The Centre for Sustainable Healthcare also promotes joined-up thinking. Dr Frances Mortimer, its Medical Director, set up The Green Nephrology Network, where patients, clinicians, renal technicians and industry partners share ideas for sustainable kidney care, and she is planning the same model for mental health.

Her colleague Rachel Stancliffe stresses the importance of preventing illness by looking to the wider environment; bringing together professionals working in green space, urban planning, architecture, transport and health. "We need cross-sector groups which understand that what they do always has outcomes for health", she says. – Mary Zaccaroli

New kit for the flying doctor

The challenge of providing effective, efficient healthcare in cash-poor rural settings with diffuse populations is inspiring innovation. GE Healthcare engineers have developed an electrocardiograph machine for the rural Indian market using technology from a 15lb machine costing $5.4 million. Adapting some off-the-shelf products, such as a bus terminal printer, they produced a portable device that is easily transportable on public transport or motorcycle and costs $1,200 less than a conventional machine.

Meanwhile, Oxford scientists and Nova Bio-Pharma Technologies have developed a way of preserving vaccines for at least six months at up to 45°C without refrigeration, by suspending the viruses in a thin film of sugar molecules. Taking it one step further, scientists from Kings College, London have contained this dried live vaccine in a microneedle patch that would allow patients to administer the vaccine painlessly without the need for medics or hypodermics. Benefits, according to research scientist Dr Linda Klavinkis, could include reduced costs in manufacturing and transportation, and a reduced risk of transmitting blood-borne disease from contaminated needles and syringes.

Innovative technology to help remote populations access medical services is just part of the solution to rural care. Other initiatives embrace the great outdoors as a resource offering health benefits, for both body and mind. Care-farming, for example, which is prevalent in the US and Europe, brings together farmers with health and social care personnel to provide social, educational, therapeutic and development opportunities. Meanwhile, NHS Forest aims to improve health by planting trees on and improving access to rural and city NHS green spaces. "There is mounting evidence that patient recovery rates improve even if they only view trees from their hospital window", said project coordinator Sarah Dandy. – Mary Zacaroli

Jon Turney is a science writer, and author of The Rough Guide to the Future.

Photo: Photos.com / Jupiter Images / thinkstock; iStockphoto / thinkstock; Kings College London; Hemera/thinkstock; iStockphoto / thinkstock

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