What is e-health & smart health trends?
What are the main trends in smart health that can be identified?What is ehealth trends?
An integrated care offer to manage the health journey
The first trend concerns the impact of ICT on the supply of care. With the development of telemedicine and shared medical records, an integrated vision of the healthcare offer is emerging. Healthcare, hospital and ambulatory professionals find themselves in closer ties thanks to the information sharing capabilities made possible by ICT. This concerns information systems, such as the exchange of expertise between professionals at a distance. Likewise, ICT allows remote monitoring of previously unthinkable patients. Finally, these technologies offer new capabilities in preventive policies with remote controls of biological and genetic constants, and in patient self-management. Thus, the idea of a fully integrated care offer bringing together specialists from health establishments, liberal professionals, and actors in the social sector, even if it encounters difficulties, no longer seems utopian. The case of Kaiser Permanente, which combines care providers and insurers in the same system, constitutes an exemplary case in this regard. This trend towards increasingly integrated systems calls for the following comments:
It is first of all a challenge because it corresponds to the expected organization of the care of a patient within the framework of a health journey. It is common to speak of health pathways to illustrate this wider scope which integrates the curative as well as the preventive side, and which also leads the concept of care at the border of health and social. With the ever increasing chronicity of many diseases, due as much to the aging of the population as to medical advances, care is now envisaged for many patients along a course which includes the health establishment, but also city medicine and other medico-social structures, as well as their domicile. By widening the scope of the activity under consideration, different actors are brought in to intervene in the most coordinated way possible: hospital professionals, treating physicians, liberal nurses, social actors, and actors carrying out new professions such as coordinating nurses or telemedicine assistants. During this course, the appearance of certain medical innovations (such as oral chemotherapy), combined with the desire to shorten hospital times and contacts (reduced length of stay, development of ambulatory medicine, control of unjustified readmissions) accentuate the tendency to keep the patient as much as possible at home, and consequently to ensure follow-up at a distance. Finally, there is a trend to recognize the preferences of the patient in a more global manner, as illustrated by the concept of “patient-centered care”, and to personalize the response. We can thus speak of coordinated and personalized health pathways for which the care offer must be as integrated as possible to respond appropriately.
The use of ICT has a structuring effect in the construction of this integrated care offer, but it should not be considered in isolation. If the structuring of information and exchanges between professionals, as between professionals and patients, is associated with the emergence of ICT, it would be naive to think that they constitute the only component of the integrated organization of the care offer. The initiatives that go in this direction are most often inspired by the Chronic Care Model which combines the use of ICT, new organizational methods (such as the creation of coordinating nurses), actions promoting patient self-management, and the establishment of a payment-type incentive for coordination. These new payment methods (capitation, payment per episode of care, global package) aim to compensate for the weaknesses of current payment methods (activity-based pricing, fee-for-service, in particular) to encourage cooperation between professionals and multidisciplinary exercise.
If these dimensions are not inherently innovative, take them head on, assess them qualitatively and understand the impact they have.
In this context, the implementation of ICT presents organizational impacts, and faces barriers. By leading to new forms of coordination, ICTs require mediators, bearers of this coordination. It is the role currently assigned to coordinating nurses, and health networks, to ensure the proper use of ICT.
The barriers mentioned in the report show for their part that the implementation of ICT is not an easy process. Their accumulation often leads to observing the paradox of Solow’s productivity: a long return on investment while the theoretical gain in efficiency is easy to determine from the start. Their resolution requires endurance and strength of conviction. Because the question of support for change is central to avoid investing heavily in a tool that would not be used. Operators must be sufficiently convinced of the contribution to overcome the technical problems of interoperability. This point underlines that the implementation of ICT cannot be decreed, but that it must be shared by the actors to ensure the dynamics of the process, and be supported institutionally. It is at this price that the increase in load towards more integrated care offers can be envisaged.
In this movement to integrate supply, the role of the hospital as well as the patient’s home is certainly going to evolve. The following example helps to understand this evolution. NXT health is an American team of people with diverse profiles (ranging from architect to hospital administrator to scientific researcher) having developed a project (partly funded by various industrialists) of the hospital room of the future, called “Patient Room 2020”. This room of the future is designed in a “patient centric” spirit where “technology becomes the connective tissue that supports the continuum of care”. Following this trend, the hospital room of the future could become the room of the patient’s home, full of vital sign detection technology and capable of regulating the individual or issuing alerts. In this way, the patient could stay at home longer and only come to the hospital to obtain expertise on very complex problems, or treatments requiring technical platforms that are difficult to transpose.
In turn, the tendency to hospital-centrism could fade, or at least take another form “The hospital [will] be repositioned: it will be able to radiate through telemedicine, and its physical footprint will be exceeded by its footprint intellectual, which should be valued. ”In this regard, these hospitals of the future could constitute, in addition to sophisticated treatment structures, powerful data centers.
The enhanced expertise of the citizen and the patient
Today, with the developments mentioned, the individual has important health information at their fingertips. It can also actively contribute to its development with the active support of increasingly large social networks. Therefore, the patient now has the keys to participate fully in your therapeutic journey and he has a critical capacity at all stages of his disease (from his diagnosis to his treatment through his drug prescription ). Citizens have the ability to organize their health trajectory, by warning themselves of the risks for it.
Beyond information, the wave of self-quantified / self-management allows the patient to develop a critical reading of his illness, the intuitiveness of the tools (popularization of information, adaptation to the person), their integration in everyday objects (smartphones, tablets, social media), the convergence of data for comparative purposes (PatientLikeMe) and finally, the algorithms which orient its behavior helping it (silent procedures for adapting to data in real time).
This newly acquired theoretical and practical knowledge leads to rebalancing the patient / doctor relationship, in the sense that the patient becomes more enlightened, even expert and autonomous in the management of his health. This need to enter a “patient-centric” dimension in the MIT Technology Review recalling that “the person least used in the healthcare system is the patient”.
Technologies for data collection and analysis on Smartphones are part of this movement from the “centric patient”, expressing this refocusing on the patient of numerous activities of early detection of the disease, follow-up or care. The tests conventionally carried out in the laboratory will soon be possible on your Smartphone (some are already done such as glucose level, blood pressure, etc.). The Smartphone could thus become “a laboratory on a chip” (“lab on a chip”), the next step in the digitization of the patient being the “laboratory in the body” (“lab in the body”), this expression symbolizing the ability to develop nanotechnologies which can be integrated into the human body and which can provide continuous information on the state of health. However, this change is not without consequences.
First, the relationship between doctors and patients is changed. Not all doctors are prepared for this evolution of the patient, who may develop resistance to it. From a practical point of view also, the consultation time (in general medicine) remains limited (16 minutes on average), making it difficult to introduce a possibly contradictory debate confronting the expertise of the patient with that of the doctor. The place of social networks and discussion forums being more and more large, these could appear in the future as a complement to the traditional relations of doctor-patient consultation.
Second, a question relates to the quality of the expertise developed by the patient. One of the dangers highlighted in this report is to observe an expertise of the patient or of the citizen based at least in part on erroneous information, or information which requires a minimum of expertise and technicality to be understood. public information, social networks, performance objectives integrated into connected tools). The quantity and variability of information are involved in particular in the emergence of cybercondriaques: the invasion of information and data produced by multiple sensors which gradually dictates a theoretical path (threshold number of steps, calories, algorithm which he considers realistic, transform the patient into a hypochondriac.
In this regard, the mastery by physicians, and more generally by health organizations and professionals, of these same information and communication tools, constitutes a real challenge. Today, the healthcare professional remains the trusted person. He must then seize this opportunity to help the patient, not to learn, but to learn better by referring him to reliable sources of information and by guiding him towards a reasoned use of these new tools.
Thirdly, following on from the previous questioning, we must ask ourselves about the potential limits of patient autonomy in managing their health. Problems arise in particular with regard to self-medication in the face of the now direct sale of medicines to the consumer via the Internet (direct-to-consumer). This is the case of Viagra, used for erectile dysfunction, which sometimes only serves a goal of improving performance, or other drugs like Lipitor, lowering cholesterol levels. To the risks of misuse of therapies is added a lack of knowledge of their undesirable effects. These can prove to be underestimated in clinical trials carried out upstream, often on a small number of people (200 for example), and do not prevent serious side effects in the case of a sale at very large ladder .
The dissemination of incomplete information via the Internet can also contribute to this phenomenon. We also think of examples as simple as sunscreens that do not protect from UVA rays, because only UVB rays are regulated in the United States.
Thus, if a progressive access of individuals to their medical information is envisaged, the quantity, accessibility (in the sense of the capacity for interpretation and analysis) as well as the quality of the information available today is not guaranteed . As a result, self-diagnosis and its direct consequence, self-medication, remain risky practices, especially when they are likely to affect millions of Internet users as is the case today. But in a more optimistic way, we can recall that there are also examples of success of an autonomous management of acts by the patient.
In the end, we can see in the emergence of this patient autonomy certain risks involved, and also many reasons for hope.
In any case, whatever the degree of dissemination, these connected tools will certainly restructure the medical landscape. One can especially imagine that they will make up for any shortages of doctors in the future.
The evolution of the insurer profession
The third trend concerns the insurance profession and its evolution. The latter may be interested, as we alluded to previously with the case of Kaiser Permanente, in becoming a care provider in search of efficiency by participating, in partnership or directly, in the development of integrated care networks. But above all, it appears that with the rise of ICT, the insurer will be increasingly confronted with questions of disease risk prevention. The impact introduced by ICT is in fact to give additional possibilities of information on the risks incurred in health individually by each insured, and to develop preventive actions accordingly. Connected tools provide capabilities for monitoring the health status of any individual up to now unthinkable (insofar as a data recording system is set up between the insurer and the insured).
This concerns the prevention of the disease, depending on the risk factors known to the person (history of cardiovascular disease, pre-diabetic state, for example), or even in principle by playing on the maintenance of a good state of health.
This concerns secondary prevention focused on known weaknesses: to an asthmatic person, we will send a warning signal if they are going to areas at high risk of crises; to an elderly person prone to falls, we will equip their floors with “magic carpets” capable of detecting suspicious movements and informing them of a deterioration in their mobility.
Finally, this concerns preventive approaches based on predictive medicine. With the conquest of the human genome, knowledge of the risk profile of developing certain diseases (in particular, cancer) becomes possible. On this observation, we can reasonably envisage preventive actions of a new type, knowing nevertheless that: at risk related to alcohol or tobacco consumption); (ii) the relationship between prediction and the onset of the disease is complex. In many cases, the genetic aspects mix with environmental factors. Furthermore, the state of knowledge is still partial. For example, we have known for the past fifteen years that the risk of developing Alzheimer’s disease is very high in people with the apoε gene. However, having this genotype is neither necessary nor sufficient to develop the disease. In other words, people with the apoε gene may never develop Alzheimer’s disease, and others without it, can. The reasons for the onset of the disease are still too unclear.
All these elements combined tend towards the development of individualized insurance cover, based on prevention measures which are itself personalized. Indeed,better knowledge of known risk factors, such as predictive factors revealed by better knowledge of the genetic heritage, should help to specify preventive actions according to the profile of each individual. The challenge that seems to be taking shape in the insurance sector is then that of developing insurance models based on personalized prevention programs in addition to curative care. It is a question of considering support services for the patient throughout his life, upstream of the illness, either directly with the insured, or via the employers, and the theme of health at work.
In this context, a first question aims to understand the role that members of the GAFA (Google-Amazon-Facebook-Apple) could play. These companies have the potential to collect data on the behavior of individuals (and therefore policyholders), and to process databases (in the context of predictive medicine) which can lead them to question their introduction into the insurance business. Their expertise plays on the collection of a very large number of data, and their processing (“Data Mining”). Based on the interview with the director of institutional relations at Google (but who obviously represents only one case), it seems that the preferred strategy is to study possible partnerships, rather than to diversify the activity. In other words, as in the case of self-driving cars, where development is envisaged with car manufacturers, the objective is to retain expertise in data processing, and to establish collaboration with operators in the sector.
However, there is already an active attitude in the United States towards “Data Mining” carried out by other actors. The Health Carolina Health system, for example, analyzes data from the tracing of the credit card of members of the system, in order to identify risky behaviors (number of “fast food” purchases). , cigarettes, alcohol and medication). This system could in the future be used to personalize insurance contracts (the more risky your behavior, the more you pay) with all the consequences that one can imagine in terms of privacy.
A second question concerns the dangers of knowing in depth the risks of developing a disease run by everyone. We can guess the dangers of a stigmatization of certain individuals carrying significant genetic risks revealed by predictive medicine. The objective is to consider forms of protection around this new knowledge as studied by various current academics.
Finally, we see the dreadful impact on the solidarity of insurance models where risks are shared. The revelation of these risks, and the differences observed between individuals, raise important ethical questions, in the context of maintaining solidarity insurance cover. The challenge for the coming years in this area seems to be to design insurance models based on personalized prevention of the insured, while guaranteeing values of solidarity in covering risks. This last observation clearly shows that the impact of ICT on health insurance coverage constitutes an issue of health democracy.
Change of scale and research tools
The fourth trend concerns the impact of digital technology on health research methods. Big data and new types of processing offer openings to multiple fields of research. As described in the report, these fields relate to precision medicine, clinical research, management research or epidemiology. There are techniques and tools for collecting and processing new data that are transverse to these various fields of application described. However, this eruption introduces an increasingly manifest debate on health research methods.
• Renewal of traditional analysis methods
Traditional statistical research methods have biases that recent methods are likely to mitigate, or at least reduce.
In particular, one of the main problems in the clinical evaluation of an individual is the systematic analogy made between the case he represents and the average person in his category. This type of reconciliation always involves a risk, as individual characteristics can sometimes present a large standard deviation from the average for individuals in the category. Through their processing capacities, current models have a possibility of more finely analyzing the uniqueness of each case. This is what personalized medicine embodies. But this is also found in other areas of application. There is in all the approaches this common will to categorize more and more finely until uniqueness.
Another difficulty in assessing a health risk is to sort out what is a genetic predisposition for a disease (like type 2 diabetes, for example), and environmental and lifestyle factors. There is a certain amount of risk written into the genome, as well as a variety of factors over which the patient can have some control – such as obesity, regular exercise, smoking, alcohol consumption . Current genetic tests also need to be discussed by a clinician capable of translating the result according to a given environment. But if this tangle requires some caution at present, predictive models have, by their learning ability (the famous “deep learning”), the possibility of improving the distinction between these two types of factors in the future .
In addition to these debates on traditional methods of analysis, it is worth emphasizing the role that the patient may have to play in the actual collection of data. As its name suggests, “Big data” is developing massive methods of collecting patient data. In this movement, connected tools, such as portals, and in general access to the Internet, have paved the way for data collection carried out by the patients themselves. It is one of the indirect effects of digital health to favor data collection channels coming directly from the patient. This is what we call the “data-driven patient”. The benefits are potentially significant in the area of clinical research. Traditional clinical trials are based on standardized data collection protocols managed by clinical research assistants. Direct transmission by patients can represent a very significant source of savings in the course of the trial. Consequently, many initiatives seek to develop methods based on data collected by patients after obtaining their consent. Through these movements emerges an evolution of research methods towards personalization. It challenges traditional approaches. It is still difficult to understand the real meaning of this questioning: will randomized controlled trials on samples – the “gold standard” of clinical research – see their place reduced? Or will they (more likely) be supplemented by other methods managing greater variability in data?
Generally speaking, the next few years should bring about an evolution in methods and also in the fields of health research, particularly in the field of clinical research.
Today, much of this new cancer data is already publicly available in the Atlas of Genomic Cancer (TGCA). It is therefore already possible to use this data in order to develop predictive models for given situations (for example the prediction of the mutation of the KRAS gene by using gene expression in patients, the response to a type of drug, etc. .). These approaches are the subject of numerous works under the expression of medicine not personalized, but precision.
However, there are limits. It is important to understand that the manipulation of a large amount of data, if it offers advantages, does not eliminate all the problems during their treatment. For example, the “noise” linked to random phenomena does not disappear with a large number of variables. There is a need to correct unwanted latent structures (preprocessing step such as background correction and normalization). Despite their large number, it is also possible that the data remains contextual. Studies are paradoxically carried out on small samples in very local situations. The challenge is to organize analyzes on a large number of patients, most often at the international level.
In addition, the manipulation of this large number of variables constitutes a major challenge: it is necessary to avoid over-learning, over-fitting (overfitting), and manage the rate of false discoveries (FDR, False Discovery Rate), especially in oncology. due to tumor heterogeneity. For example, a test can be analytically valid without clinical utility. Finally, despite its gigantic aspect, the data analysis, the hypotheses and the associated prediction models, are based solely on the so-called coding genome, in other words on only 1% of the total genome. It is easy to understand that potentially decisive information can be omitted from the results presented. The challenge is to sequence the entire genome of a tumor and compare it with the genome of a patient without cancer. There is great hope, the cost of this research decreasing as knowledge accumulates.
• New paradigms of medical practice from digital health
One consequence of the expansion of research fields is the potential influence on medical practices.
On the one hand, the new data processing capabilities introduce pure “data analysts” into medical practice, alongside doctors. By predictive models, these analysts can claim a definition of therapeutic strategies as relevant as that traditionally carried by doctors.
On the other hand, the involvement and initiatives that the patient can take to help with the collection and processing of data reinforces the co-constructed nature of knowledge (already mentioned previously with the trend towards patient autonomy), in a permanent, iterative, reciprocal and cooperative process between patients and the medical profession throughout the life course.
Finally, so-called precision medicine commits to a new classification of diseases, as we have seen in the case of cancer. This redistribution in the taxonomy of diseases will also have the probable concern of better personalizing the diseases, and consequently the appropriate therapies, as the movement of targeted therapies is already committing to.
Which health system in the future?
The first level of analysis that we have just closed consisted of identifying major trends based on already observable technological developments. Four main trends on the integration of the care offer, patient autonomy, the development of personalized prevention services by insurers, and the evolution of methods and fields of health research have been identified. A second level consists, on this basis, in studying the impact of ICT on the health system as a whole. In this respect, the evolution that seems to be taking shape is that of a substitution of a hospital-centered system, mainly positioned on curative time by a system giving more space to home care, and to preventive measures, upstream of the disease. All this points towards health paths managed at the different stages of life.
• A system organizing life courses
To start the exercise, it is necessary to take one by one the highlights from the previous parts, and deduce the effects on the health system.
The first of these facts concerns the possibilities offered by ICTs to experiment with more coordinated and personalized paths during illness. Remote monitoring can be envisaged thanks to portals and connected tools, as we have seen. This works in favor of keeping the patient at home, or at least limiting his visits to the hospital. This significant feature of the impact of ICT on the supply of care is part of a general trend, already affirmed: the appearance of medical innovations (such as oral chemotherapy), combined with the will of public policies to shorten the time and hospital contacts for mainly economic reasons tend to keep the patient at home. On the basis of this observation, we can deduce the transformations that the home and the hospital could experience in the near future.
With domomedicine, tomorrow’s hospital room could become the patient’s home room. The latter, full of vital signs detection technology and capable of regulating the individual or issuing alerts, could indeed offer the patient the possibility of staying there as long as possible. Coming to the latter’s hospital would only be considered to obtain expert opinions on very complex problems, or treatments requiring technical platforms that are difficult to transpose. Under these conditions, the annoying drift towards hospital-centrism would also be brought to disappear, or at least to fade, giving way to sophisticated treatment structures, eliminating certain specialties whose management would be outsourced. Conversely, these hospitals of the future would integrate powerful “data centers” to allow the necessary remote monitoring. The painting may seem futuristic. However, some recently built hospitals are already resolutely turned in this direction, such as the Samsung Medical Center in Seoul.
The second highlight concerns the possibility offered to the patient of autonomously managing certain actions of their care using connected objects and community sites. Topol deduces that a large part of the diagnostic and surveillance phases of the disease could be assumed in the future by the patient himself, in place of the healthcare professionals. The development of connected tools could thus largely contribute to a restructuring of the medical landscape, technology replacing human expertise in many cases. We are entering there straight into the field of prediction, with all the risk involved in exercise. But whatever the degree of substitution, the spread of ICT in health will represent a credible alternative in the coming years to make up for future shortages of doctors, as American politicians have already pointed out.
Finally, third highlight, better knowledge of risk factors, in particular through genome analysis, should help to specify preventive actions based on the profile of each individual.
By associating this possibility of developing new prevention services with the previous observation, a curative system based on health paths, digital health is invited to an enlarged conception of the health system. In this conception, taking charge of health would no longer be limited to the curative stage alone, but would be conceived throughout life. The line between health and well-being is also increasingly being drawn. At each stage of life, the citizen would develop an increased awareness of the maintenance of good health. You could protect yourself from the risks of illness, cultivate a certain state of well-being, and if he ever fell ill, be taken care of within integrated care networks. It would no longer be a question of a course of care or health, but of life: that is to say a “tailor-made” management of his health course throughout your life.
.Two factors challenge
In the coming revolution, two factors seem to have to be taken into account to explain the possible pace of change.
The first is the question of the interoperability of information and communication systems. Other sectors (such as air traffic control, for example) illustrate the difficulty that this dimension can represent in large systems, and the time that the search for efficient solutions can take: years, sometimes tens of years. Today, almost all of the institutional and human players in health networks have information systems, whether it be HIS (hospital information systems) or medical office management software. But the question of the interoperability of these systems and their dialogue remains open, and the time that may take to develop solutions is difficult to predict.
The second is the ethical question. The production, exchange, and even processing of data as sensitive as that relating to the most intimate of an individual, his health, pose significant ethical and deontological problems. Likewise, the question arises of a possible widening of inequalities in the care that can result from the development of ICTs and therefore of how to manage this risk in a united manner.