COVID-19: the impact on digital health and future considerations

Thinking through the present operational challenges, restrictions imposed by the lockdown and changing attitudes and behaviours, it appears that digital health has been provided with an opportunity to prove its worth. I believe that, in order for digital health to have an impact that is both meaningful and sustainable, we must look ahead at both the medium term (six months from now) and the longer-term (one year from now). 

Until a couple of weeks ago, the digital health sector has been struggling to scale their products and innovations. The NHS has always been cautious (rightly so in some cases), with decision making slow and with many layers.

In addition to the catch-22 situation of requiring evidence (and having to find early adopters to get the evidence), getting budgets approved could be challenging, especially where benefits were delivered in the medium term or in a location in the healthcare ecosystem different to the ‘budget holder’.

 All that has changed with COVID-19.

The effect it is currently having on the digital health sector is unprecedented, with a marked acceleration in the adoption of technology across the NHS. To maximise the positive impact in a sustainable manner, there are key medium and longer-term elements we should consider.

The NHS policymakers, managers and frontline staff are working to meet the immediate operational requirements and dealing with the substantial disruptions caused by COVID-19.

First, strict measures on social distancing and self-isolation result in the need for virtual ways of working, both for staff managing internal operations and clinicians interacting with patients.

Second, with the number of people infected (including NHS staff) continuing to increase, we need more effective and safer ways of managing patients including increased hospital capacity, intensive care equipment and not to say the least, appropriate protective equipment for front line staff.

Third, with a vaccine still many months away, there is a continuing need to accurately monitor, predict and plan for ongoing infection including testing, contact tracing and efficient isolation of at-risk and exposed people.

The NHS and the public are responding rapidly. 

The government passed emergency legislation to amend the Mental Health Act to relax requirements for sectioning a patient. The Excel centre was converted into the 4,000 bed Nightingale hospital in 9 days. NHSX issued pragmatic guidance to clinicians on information governance related to videoconferencing, messaging, using their own devices and sharing of information.

The NHS also put in place wider measures to roll out video conferencing in primary care including fast-tracking assurance of video products on the new Digital Care Services Framework (12 suppliers were appointed on the 23rd March).

Adding to that, an Ipsos MORI survey revealed that there had been an 80% increase in the number of people that had used an online GP in the 3rd week of March compared to in the 2nd week, demonstrating that the general public is willing to adopt these technologies should they be made available, which longer-term could result in significant improvements to the speed in which a patient can be reviewed and appropriate care delivered.

A survey of patient contact preferences for a GP consultation agency found that 47% of respondents preferred a phone consultation, compared to just a quarter (25%) who requested a face-to-face consultation^[1]. 

Professor Marshall, Chairman of the Royal College of GPs stated on the 11th of April that the in-person GP appointments had drastically reduced from 80% in the last year to 7-8% over the last 3 weeks. He also pointed out that the majority of the virtual consultations were being done over the phone rather than via video call. The preference for more simple technology, like phone call consultations, means that the barrier of entry is a lot simpler and is able to be rolled out nationally more efficiently than implementing more complex technology systems.

The demographics of digital health adoption also appears to be changing. Analysis from online pharmacy service Echo shows a dramatic increase in over 65s using their service over the course of March^[2].

The pandemic has also seen rival companies work together in an interoperable fashion, with Apple and Google recently announcing they are working together to create a COVID-19 symptoms tracker to work across both iOS and Android devices. 

Mindwave partner and start-up Thalamos is just one example of a health-tech company that has adapted to support the industry during the pandemic. With increased pressure on mental health services as a result of COVID-19, Thalamos is responding to new emergency Mental Health Act legislation, by accelerating new features and functions of their mobile application for social workers and doctors.

The temporary emergency legislation means that one doctor, rather than two, can sign off a Mental Health Act assessment. These measures have been introduced because the government is concerned that Covid-19 will reduce the number of mental health professionals available to help people whose mental health places them at risk.

These new features will not only support mental health practitioners to undertake their work more efficiently, they will also afford a degree of social distancing, insofar as digital notes can be transferred safely to the hospital, rather than by the practitioner having to deliver them in person. By making these changes, we hope to decrease the pressure on services and make life easier for doctors and social workers. 

Six months later

 In the medium term, following the firefighting phase, we should hopefully enter recovery. Within this phase, there will be three key elements to consider:

First will be around how care is delivered. Patients, clinicians and the general public will have been used to virtual interactions, online transactions and getting things done from home (including deliveries). Having gone through managing minor injuries, illnesses and routine illnesses without going to see their GPs in person, visiting the local A+E or outpatient clinic, both patients and clinicians may well consider virtual consultations as (at least) a preferred choice.

Professor Marshall believes that up to 50% of GP appointments may be conducted virtually. With NHS resources and clinician’s focus diverted to COVID-19 related patients, medical emergencies and people with acute illnesses, those with chronic conditions will have been provided with information, alternate support and signposted to (including by peers with their condition) to apps and technology solutions.

This will provide a good foundation to identify, develop and deploy sustainable technology-enabled self-management pathways.

Second will be around how we foster a meaningful technology ecosystem. Due to rapid uptake, there will be a number of solutions for solving similar problems. Fragmentation will be widespread. Due to rapid implementations, there will be limited unifying workflows or interoperability. Evaluations that were less rigorous than usual will result in some less effective and more risky solutions in the system.

A large number of new implementations will have been implemented for ‘free’ or on ‘extended trials’, commercial terms and who pays for what will have to be figured out quickly. To meet these challenges, the ecosystem will need to be based on open standards and have transparent evaluation and assurance frameworks. Some solutions will have to be replaced with others that plug the gaps.

Third will be around supporting staff through the change. Staff will need upskilling on the new ways of working. These skills will undoubtedly include digital health and communication-related skills. Communication will take a whole new form including supporting patients, carers and family virtually and also on how to work effectively with cross-organisational colleagues in social care and local government.

The ability to support mental health issues will no longer be the responsibility of a select few.  Supporting users to be aware of and use the solutions effectively will increasingly become important once the hype dies down and the necessity for virtual first recedes.

 A year from now

In the longer term, the focus will be on consolidating the new norm. I believe that within this phase, the following will be the key focus areas. 

First, legislation and assurance frameworks will need to be rehauled. Based on lessons learnt and evaluation of the outcomes based on changes made in the past year, legislation should not hinder the adoption and scaling of digital health, and should afford a degree of flexibility for the future.

Having said that, as a counter-balance, assurance levels must be implemented to ensure the appropriate levels of risk management and patient safety are considered. This should also factor in emerging technologies such as artificial intelligence.

As well as rules and policies, it will be important to equip the clinical workforce to be able to better understand current technology trends and solutions and to determine which are effective and could be beneficial to their clinical practice. This education should start at undergraduate level.

Second, incentives and implementation must be optimised. At a basic level, funding flows must be restructured to account for the nature of digital solutions and wherever possible budgets should be pooled to enable pathway-level consideration to avoid ‘siloed budgets’ leading to disparity.

It would also be (high) time that appropriate payments are moved on to an outcome-based model. There is little point paying purely for shiny kit and the latest tech.  At the start, adequate attention must be given to acquiring and engaging with users. Extra resources and specialist skills where appropriate should be allocated to support the implementation of the solutions.

 Finally, the environment for continual innovation must be designed and nurtured to ensure progress does not stagnate. We must reflect on the factors that enabled rapid adoption, take time to understand user requirements and strike the correct balance between openness and risk management.

To fully identify and understand all aspects of these considerations the health tech industry, policymakers, health and social care organisations, clinicians, patients and the wider public must all collaborate. This crisis has highlighted the importance of cooperation and the collective power of groups. I hope we can all work together to realise the maximum potential of digital health.