In our EHFF Newsletter, posted October 23rd, I promised a review of EHFF’s changing view of the future over the 15 years or so that EHFF has identified as a futures organisation. Here’s the third of the levers for change in the process of healthcare transformation that we had identified.
eHealth: for the WHO, eHealth encompasses not only internet-based healthcare services but also modern advances such as artificial intelligence, mHealth (mobile health), and telehealth, which collectively aim to improve accessibility and efficiency in healthcare delivery.
Robert Istepanian, who coined the term mHealth, in a review article from 2022, https://pmc.ncbi.nlm.nih.gov/articles/PMC8998037/pdf/ijerph-19-03747.pdf ‘m-Health in retrospect, the Known Unknowns’ locates eHealth within the umbrella of digital health, which includes the ICT domains of AI, big data and genomics, as well as the quartet of telemedicine, telehealth, eHealth and mHealth. EHFF’s interest within this massive arena has focussed on mobile applications and sensing devices, seeing them as the aspect of eHealth that promises most progress in enhancing patient/citizen education and self-management (see our 2018 blog: https://ehff.eu/ehff-and-digital-a-position-statement/ ).
We met the developers of mySugr, a very successful diabetes management app, at the Health 2.0 conference in 2016, prior to their business being acquired by Roche. What impressed us was that part of the development team had type 1 diabetes and therefore provided lived experience which contributed to their product content. In fact, earlier that year, funded by the Robert Bosch Foundation, we held a two-day roundtable in Berlin on end-user involvement in eHealth product development, with 32 attendees representing most of the relevant stakeholders. The final report is on our website: (https://ehff.eu/ehff-newsflash-berlin-rbs-seminar-revisited/ ). Key highlights in the group’s conclusions were the barrier of excessive preoccupation with data security, the importance of digital literacy for all end-users (i.e. healthcare professionals included), the handicapping effect on potential change of ‘short-termism’ and ‘bolt-on’ technology versus building new systems around the new technology.
Looking at this area more widely, Istepanian’s review, quoted above, raises a much wider matter for concern namely, while the global consumerization of m-Health in the numerous areas of healthcare, fitness and wellness is unprecedented, this has a created a divergence between ‘mobile health capitalism’ and the ‘science of mobile health’ and the creation of what he terms the ‘m-Health schism’. This schism is sustained by the continued domination of the former at the expense of the latter. His concerns about the ‘science’ of mobile health were echoed in a previous meeting of digital health professionals at the Health 2.0 meeting referred to above, who who were troubled by such issues as the clinical evidence supporting digital health solutions being insufficient, lack of mechanisms to gauge the compliance of apps and solutions with their minimum data protection requirements, organisations wanting standardized solutions while individual users and patients wanted personalized solutions, concerns about misinformation and finally, digital training and knowledge transfer being insufficient. Nearly ten years on, how many of these concerns have been properly addressed, while in the same period, new applications have been flooding onto the market?
My colleague and fellow EHFF advisory group member Ales Bourek pointed out the paradox that still hangs over this, which is that when new apps come onto the market without any HTA (Health technology assessment), unlike the situation with both new pharmacological and products designated as medical devices, which have strict regulation (with the latter, the European MDR e.g.), reinforcing the point made above, there is no adequate information required to demonstrate the new apps’ efficacy (let’s be blunt – it leaves consumers/citizens vulnerable to what in past times were labelled ‘snake oil salesmen’).
To press the point, despite the remarkable technological advances and the widespread adoption of mobile health solutions, there remains a persistent gap between innovation and robust scientific validation. The rapid pace of digital health product development often outstrips the establishment of rigorous evaluation frameworks, resulting in a marketplace teeming with applications whose clinical effectiveness and safety are not always thoroughly assessed. Moreover, the tension between standardisation for organisations and personalisation for individual users continues to challenge both developers and end-users, highlighting the continuing need for ongoing dialogue and collaborative problem-solving within the sector.
As referred to in the previous section on innovation, eHealth is plagued with promotional hype of new developments, to encourage what often may be massive investment by companies and others aiming to make serious money from what may in fact be relatively untried products, in the sense that, while technically impressive, their impact on health is poorly documented. The hype of AI is a classic example. A balanced systematic review of current advantages and disadvantages of AI in Health is: Chustecki. M. Interact J Med Re. 2024 Nov 18:13:e53616.doi: 10.2196/53616.
Future of eHealth?
There is no doubt that there have been extraordinary developments in health tech. in recent years. Compared to 20 years ago, going to the optician and having a retinal scan, to the dentist to have a 3D scan of your jaw and corresponding improvements in the results from your MRI are now relatively commonplace. Easy to manage online video conferencing is routine and sometimes substitutes for face-to-face meetings for patients with healthcare staff. For many of us, having our test results and other messages sent to an App on our smart phone by our local primary care team is also the norm, as is comprehensive website advice and information from the National healthcare providers.
Having acknowledged all of this, there are three trends that should cause particular concern; the proliferation of commercial offers for chat GPT as a solution in healthcare and the associated hype of AI (both clearly motivated by ‘health-tech capitalism’), increasing evidence of misinformation being powerfully promoted via social media, leading to a crisis in trust of mainstream science and finally, the erosion of human sensibility linked to predominantly online contact (the importance of non-verbal cues you lose online as opposed to when face to face is an obvious example).
Given the present realities of healthcare systems under stress, problems with staff numbers and the power of commercial interests, accommodation will have to be made, even if less than satisfactory. The question that can’t be answered is to what extent the principles of care, compassion, respect for the other, avoiding harm (physical or psychological) will be eroded by said compromise. As futurists we can construct alternative scenarios, but currently it seems unlikely that, were we to do so, those who have powerful vested interests would pay them any heed. This is no reason to stop championing the values which we believe must be preserved if we are to retain a humanity-based service. It is the same uncomfortable conclusion we reached in considering the future of patient empowerment.