One word: implementation.
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Increasingly, I’m convinced that the underappreciated challenges of implementation describe the ever-expanding gap between the promise of emerging technologies (sensors, AI) and their comparatively limited use in clinical care and pharmaceutical research. (Updated disclosure: I am now a VC, associated with a pharma company; views expressed, as always, are my own.)
Technology Promises Disruption Of Healthcare…
Let’s start with some context. Healthcare, it is universally agreed, is “broken,” and in particular, many of the advances and conveniences we now take for granted in virtually every other domain remain largely aspirational goals, or occasionally pilot initiatives, in medicine.
Healthcare is viewed by many as an ossified enterprise desperately in need of some disruption. As emerging technologies shook up other industries originally viewed as too hide-bound to ever change, there was in many quarters a profound hope that advances like the smart phone or AI, and approaches like agile development and design thinking, could reinvent the way care is delivered, and more generally, help to reconceptualize the way each of us think about health and disease.
In particular, these technologies offered the promise of helping improve care in at least five ways:
- From reactive to anticipatory
- From episodic to continuous
- From a focus on the average patient to a focus on each individual patient
- From care based on precedent (previous patients) to care based on continuous feedback and learning
- From patient-as-recipient of care to patient-as-participant (and owner/driver of care) – a foundational theme of both the PASTEUR translational medicine training program Denny Ausiello and I organized in 2000 (summarized in the American Journal of Medicine, here), as well as of Eric Topol’s The Patient Will See You Now (my Wall Street Journal review here).
As Denny and I wrote in 2013, this time in the context of our CATCH digital health translational medicine initiative, emerging technology:
“…provides a way for medicine to break out of its traditional constraints of time and place, and understand patients in a way that’s continuous rather than episodic, and that strives to offer care in a fashion that’s anticipatory or timely rather than reactive or delayed.”
These technologies also afforded new hopes to pharma, in particular, the ability to:
- better understand disease (assessment of phenotype and genotype that’s at once more granular and more comprehensive);
- better understand illness/patient experience of disease (can capture more completely and perhaps more quantitatively and in more dimensions what it feels to experience a condition);
- forge a close connection with patients, and add value beyond the pill. The idea of moving from assets to solutions is a perennial favorite of consultants (this, for example).
… And How’s That Going?
And yet, here we are. While some consultants suggest we are further along than even their extravagantly optimistic predictions of 2013 had imagined, my own conversations with a range of stakeholders suggests progress has been painfully slow, and the practice of both medicine and drug development generally have not felt the impact of these emerging technologies, to put it very politely (and most experts with whom I’ve spoken over the last several months have been far blunter than that).
As Warner Wolf used to say, let’s go to the videotape. Consider some of the published, peer-reviewed studies evaluating digital health approaches:
- Patients invited to share tracker data with providers via EHR: little initial traction.
- Health coaching and telemonitoring after heart failure patients discharged: no impact on 180-day readmission rate.
- Electronic pill bottles plus financial incentives on patients after discharge following heart attack: no impact on medical adherence or outcomes.
- Smartphone self-monitoring: no impact on healthcare costs or utilization (especially striking since study was done – and to his credit, published – by smartphone-in-health champion Eric Topol).
- Fitness trackers in promoting activity and driving weight loss: multiple studies (for example, here, here) showing absence of durable impact.
Given these data, it may not come as a great surprise that a soon-to-be-published review (previewed by its lead author, Brennan Spiegel, on twitter) representing a systematic evaluation of high-quality randomized control trials reportedly finds that “device enabled remote monitoring does not consistently improve clinical outcomes,” according to Spiegel.
The struggles of digital health to demonstrate value are not new – see this post from January of 2014 – nor are they exceptional in medicine. In fact, as I’ve previously noted, many technologies and approaches thought intuitively to offer obvious benefit turned out not to, from the use of bone marrow transplant in breast cancer to the use of a category of anti-arrhythmic medication following heart attack to the routine use of a pulmonary artery catheter in ICU patients. In each case, benefit was thought so obvious as to question the ethics of even doing a randomized study, and then studies were done refuting the hypothesis.
Technology Adoption In Pharma
Doubts about efficacy are also one of the reasons pharma has been extremely slow to adopt some new technology, concerns that have been validated by some early pilots. For example, I am aware of what seemed to be the perfect case of delivering a solution rather than a product: a company made a surgical product, and invested significant resources in developing a service that provided useful post-op advice and support (delivered by highly trained nurses) to patients who received the product, thus helping the patient, the surgeon (unburdening his or her office, while simultaneously helping drive better outcomes), and the company, by making it’s product more attractive. Result: I have been told that the service ultimately was shut down, because few patients availed themselves of it.
Article source: https://www.forbes.com/sites/davidshaywitz/2017/12/10/winning-health-tech-entrepreneurs-will-focus-on-implementation-not-fetishize-invention/