Where Tech Culture Meets Healthcare: Chronic Disease and The Promise of New Interventions
Startups need to stop working in silos, engaging doctors, health care administrators, communities and other system players.
While it is well known that chronic diseases such as cardiovascular conditions, diabetes, cancer and respiratory diseases are the leading cause of death in Western societies, what is perhaps less well known is that these chronic diseases are starting to overtake infectious diseases as the leading cause of death even in low and middle-income countries. This is an injustice in many ways: marginalized groups everywhere tend to be exposed to more environmental and lifestyle risks to these diseases, have less access to life-saving interventions and preventative care, and die more from them. According to the World Health Organization, almost 75 percent of the burden of deaths from chronic diseases is actually borne by low and middle-income countries.
In most of these countries, the health and economic burden is much worse because not only are their health systems ill-prepared to handle this new burden, but chronic diseases also strike individuals in their economically productive years. So while one is more likely to develop a chronic disease in their later years in a country like the United States, in a country like Nigeria it is more typical to develop a chronic disease while you are still working. What this means is that not only will you be sick, you might be pushed into poverty along with all the family members who depend on you for their sustenance. Add this to the stigma of some chronic conditions, unplanned urbanization in most developing cities, a globalization of unhealthy Western lifestyles, and the absence of well-developed risk pooling systems, and you have a disaster.
The connection between chronic disease prevention and management, and technology
The changing nature of health needs makes technology more and more critical. As people live longer and chronic diseases begin to kill more people than infectious diseases globally, health needs will increasingly be met outside the context of acute hospital-based care. Perhaps there is a role for technology to play in not only reducing risk, but providing preventative care and health education.
Emerging health needs require health services that go beyond the context of the doctor’s clinic and also require services for a much longer period of time. Technology can lead to improvements in the quality of care given this new healthcare landscape, providing individuals with more agency in managing their health and wellbeing. There are abundant ways that technology can respond to the need for comprehensive and preventive care that goes outside the doctor’s office. One of these is through sensors: from implantable monitors for blood glucose, to portable blood pressure cuffs, to wireless oximeters. Technology can also serve as a communication tool, in the forms of apps, devices and other disease management tools that aggregate patients’ data and communicate it to their providers and/or to the patients themselves. Wireless technology, the phones and internet allow for remote care in the form of tele-health and remote monitoring of patients. Technology also helps with storing and presenting data on health through tools like electronic health records that inform decision making, self-care, quality improvement and action.
Technology can also provide data for more effective public health decision-making. Morris and colleagues at the Institute of Public Health at the University of Cambridge showed that there is a significant time lag between when available knowledge hidden away in scientific journals is actually used in any meaningful way in the ‘real world’. Data in scientific journals takes many years before it is used in the real world, and oftentimes policy-makers do not inform their decisions with data because they are starved for time and/or do not have the resources and skills to access scholarly research. Thus, policies makers may end up relying on anecdotes, feelings, hear-say, politics and groupthink. Making decisions without any connection to the research or evidence is never a good thing for public health, but the technology sector can fill the need for data by translating scholarly data into interactive, informative and even entertaining forms that are more accessible to the general public and to decision makers.
Despite these promises of technology, new technology interventions such as fitness apps and devices for disease management have been limited in improving public health outcomes. A key reason for this is that health technologies typically take the form of commercially-provided innovations focused on the individual. Commercial innovations in health technology help to manage diseases and reduce the fragmentation of care, yet there is not much evidence to indicate that these technological innovations create superior health outcomes across populations. Why? One key reason is that commercially-provided innovations are usually not integrated into the broader system of care. Without integration into the care system, these technologies will be out-of-reach for populations that need them the most, thus limiting their impact on population health.
The integration of health technologies is crucial for improving health outcomes, and yet there are many reasons why this process of integration fails. One of these reasons is that there is a significant gap between the world of health technology startups and the world of scholarship. Inventors of health technology may not be as interested in the scholarly aspect of their work. They may not bother to carefully demonstrate the impact of the device on health in a scientific and accessible way. A lack of focus on effectiveness affects the uptake of innovations: gatekeepers will not be confident enough in these innovations to adopt them unless there is a sense of accountability on the part of technologists.
If the data to show that your app actually improves health is scanty at best, the reluctance of healthcare providers to adopt it is understandable. If the data to show your device works is not available, researchers, funders and doctors in other parts of the world looking for solutions to problems will not discover your device. One may implicate the start-up culture in this gap, given the emphasis on the new against the old, the positioning of freedom against bureaucracy, innovation as against the system, and individuality against conformity. But what if a middle ground between these values is the real road to the future? An easy way to bridge these cultural gaps comes to mind immediately: innovators can partner with researchers who work in implementation research and fund them to evaluate new interventions, discovering ways for products to be improved and publishing such findings in peer-reviewed journals.
The role of evidence and systems thinking in ensuring wider access to technology
Regina Herzlinger cites case studies of technological innovations that failed to scale in the Harvard Business Review. One was an acid reflux device that could help gastroenterologists to correct acid reflux without needing complicated surgical procedures, and thus – surgeons. The device failed because it did not consider the politics set up by changing the power dynamic between the surgeons and gastroenterologists. The device-makers also did not work with insurers, so hospitals would not be reimbursed. Medtronic, on the other hand, was more skilled at navigating systems. They worked directly with surgeons who would implant their heart defibrillators to understand the problems and procedures that they needed to pay attention to. They used clinical trials to show safety and efficacy, therefore making it easy for insurers to reimburse providers. The role of these systems players also ties into another factor that may limit the use of technological innovations: failure to consider drivers of innovation.
Drivers of innovation in health systems include providers, healthcare workers, management, and policy makers, amongst others. Consider a health worker who may see a technological innovation as a potential threat to their job, or the power imbalance that can be created when a new innovation is introduced. If a community health worker who previously did not need any certification is suddenly told that she will need to take an online training before she can keep her job, she may resist the innovation. On the other hand, if there are financial incentives for healthcare providers who adopt electronic medical records, they may be more enthusiastic about using a new technology. Innovators need to carefully consider the drivers of innovation within health systems, identifying the right incentives, allaying these drivers’ concerns, and partnering with them to enable innovations to penetrate the health system.
Another issue that needs to be considered is the role of policy and regulation. Innovations are usually taken up slowly in health systems that are tightly regulated. For example, where health is provided by the government or through insurers, and not out-of-pocket, these providers need to contain costs while providing care for all. Without such regulations, expensive technological devices would increase healthcare costs and reduce access and equity. This raises two questions: how do we create cost-effective health technologies that do not strain health systems financially, and how do we ensure that policy environments are not so tightly regulated that they militate against the introduction of value-added technology? Innovators will need to work at producing cost-effective solutions that will be more likely to penetrate health systems, which are always looking to contain costs. By educating themselves about the policy environment and regulations, innovators can understand how to navigate barriers to the diffusion of their innovations.
The promise of technology in ensuring inclusive and equitable health outcomes
We all win when cost-effective health technologies are adopted into our health systems, but there is a lot of work to be done. Start-up cultures will need to embrace systems, while systems will need to embrace innovation. Innovators and startups will need to stop working in silos, engaging the systems players they hope to work with, such as doctors, health care administrators, and communities. They will also need to see the relevance of research and academia, which many in startup culture tend to dismiss as bureaucratic.
The social justice implications of this collaboration are profound, since the integration of a health technology into the system will likely mean that insurers may reimburse for it, thus allowing access for many. Integration of innovators with the broader healthcare system will provide advantages for all of the population, not just those can afford it, thereby improving the quality of care, preventive services and health outcomes for the population at large, and not just a few elite.