Tackling the barriers to the uptake of technology enabled care
11 April 2018
Posted by: Matthew Grek
All innovations can have difficulties when it comes to practical implementation for a variety of reasons. This also happens in scientific research.
What makes the scientific enterprise feasible is the realization that, although science can never provide complete and definitive explanations, limited and approximate scientific knowledge is possible. This may sound frustrating, but for many scientists the fact that we can formulate approximate models and theories to describe an endless web of interconnected phenomena, and that we are able to systematically improve our models or approximations over time, is a source of confidence and strength.
As the great biochemist Louis Pasteur (quoted by Capra, 1982) put it: Science advances through tentative answers to a series of more and more subtle questions which reach deeper and deeper into the essence of natural phenomena. (1)
The continuous progress of science and paradigm shifts
This view, of the continuous progress of science, was radically questioned by the physicist and philosopher of science Thomas Khun (1962) in his work ‘the Structure of Scientific Revolution’.
Khun analyzed that, while there are long periods of "normal science", there are also periods of "revolutionary science", in which not only scientific theories but the whole conceptual framework where they develop undergo radical changes, which abound in the concepts , values, techniques, etc. Khun called them "paradigm shifts".
He describes paradigm shifts as: "A constellation of concepts, values, perceptions, and practices shared by a community, which forms a particular vision of reality that the basis of the way the community organizes itself."
The basic tension is one between the parts and the whole. The parts have been called mechanistic, reductionist, or atomistic; the emphasis on the parts on the whole, holistic, organismic, or ecological. The holistic perspective is known nowadays as “systemic” and the way of thinking it implies as “ Systems Thinking”.
According to Capra (2007), modern scientific thought did not emerge with Galileo, as is usually stated by historians of science, but with Leonardo da Vinci (1452–1519). One hundred years before Galileo and Francis Bacon, Leonardo single-handedly developed a new empirical approach, involving the systematic observation of nature, reasoning, and mathematics – in other words, the main characteristics of the scientific method. His science was radically different from the mechanistic science that would emerge 200 years later. It was a science of organic forms, of qualities, of processes of transformation.
This ‘mechanistic’ worldview was brought about by revolutionary changes in physics, astronomy, culminating in the achievements of Copernicus, Kepler, Galileo, Bacon, Descartes and Newton. The conceptual world framework created by Galileo and Descartes, with the world as a perfect machine governed by exact mathematical laws, was completed triumphantly by Isaac Newton (1642-1727)
To cut a long story short, in the 21st century we are jumping from Newton’s conceptual and mathematic world to the world of Quantum physics, closer to the holistic and nature-based vision of Leornado Da Vinci!
Through this brief introduction we’ve introduced the question about the impact of science on digital technologies and the barriers to implementation.
Lack of a comprehensive digital health narrative
The first barrier to the uptake of technology enabled care is the lack of conceptualization and clarity about the meaning of digital technologies and the potential impact in healthcare.
Despite digital technologies exisiting for decades, the real digital revolution is only recent, mostly due to the arrivals of the Internet, Cloud computing and Smartphones. In just a few years we’ve moved from Information Technology (IT) to Digital Technology. In this period we’ve also had a number of innovations arrive, including: eHealth, mHealth, dHealth, health Apps, 4 Health, Telemedicine, patient remote control, Artificial Intelligence, Big Data and Analytics, Robotics, to mention just a few. Everywhere you look are things that didn’t exist 20 years ago.
In short, it’s a mess. We are talking chaos. There is no narrative that explains the “whole” and the role of the “parts”. We are, as Khun said, living through a “paradigm shift”. It is not only the technology that matters; it is the disruption it creates and that is affecting the whole health ecosystem.
Everything is related to everything else
The complexity of the digital revolution, makes it difficult to effectively explain the impact of digital health and all the sub areas. The interrelation across all these technologies is endless. We cannot mention health apps without talking big data, patient remote monitoring doesn’t work without analytics, imaging and robotics… Life sciences are based on evidence. Longer term it will be difficult to avoid some clinical evidence of the digital technologies, adding more complexity. Back to science instead of simply believing in the technology! It’s not the technology the problem, it’s what the impact is in healthcare results and patient quality of life.
So, there is a need to build up a narrative which explains in a comprehensive way the potential and the limits of the new technologies. The only way to make some progress is to gather all the health stakeholders to design a digital health construct, with clinical evidence.
What happens when different health stakeholders look at Digital Health!
Seven questions for a digital health construct
To achieve a digital health construct it is necessary to ask the right questions of healthcare services:
- How can the concept of health is redefined? We know from scientific evidence that in 21st century health is dependent on genetics, behaviour, environment, economy and social and quality medical expertise available. How can we develop a new concept which integrates the several factors influencing health?
- Which objectives do we plan to achieve in healthcare services? What about integrated care?
- How can citizens be motivated to keep healthy, and how can patients can be more informed and proactive?
- Which data is crucial for precise diagnostics and therapeutics?
- Which dots must be connected to deliver more efficient, safer and faster healthcare services?
- At which point, and when, should health prevention and early diagnostics be available?
- Is our organization ready to change the way we are working?
A key question: Who should put these questions, who can answer, and who should implement the answers with the support of digital technology?
Heatlthcare systems are complex
Public and private health systems are complex organizations. They generally depend on the public administrations, or private companies/investors.
In the public sector the decision-making process is generally slow, the purchase of external services is very regulated, and the dynamics of public organizations are very conservative, avoiding risks, with a short-term vision. Policymakers need almost immediate results. The strength of trade unions is important, and it is not always easy for them to be agile and able to change. In some cases, several fears are detected as the digitization of health organizations could result in a reduction in human resources.
In the private sector, the issue of investment needs guaranteed results. This cannot always be the case with innovation as clinicians have little time and are not able to experiment or implement processes that may alter their working habits.
A lot of tools, which one is the right one for the job?
Clinicians in turmoil
Most of the healthcare professionals, doctors, nurses, pharmacists, biologists, psychologists, social workers, etc., are highly qualified, following a permanent formation, in order to apply the most recent results of the scientific research. The challenge is that they often have to work under stressful conditions because of the care pressure of the organizations they belong to. Their agendas are usually full and they cannot always care for their patients with the promptness and time they want or is required.
In this situation, the last thing professionals expect is to have to implement new processes or use innovative tools that need time to implement and become familiar with; not forgetting that there is also the need to communicate and educate the patient who will also have to adapt.
Professionals have different views about new technologies. There is often a generational gap between those who have been born practically in the digital world and those who, with more years, must make an important effort to understand and adopt the innovations. However, most clinicians are willing to use digital technologies if they can improve the patient's diagnostic and therapeutic processes.
Challenging the power of the clinician
With transversal technologies (is those that cut across other technologies/ processes) that create greater transparency, as in the case of the Electronic Medical Record (EMR), a series of insecurities arise as they can challenge the power that, to date, health professionals have enjoyed. Now eith the EMR, a clinical record (which previously rested in the drawer of the professional's office), can be seen by other professionals, duly authorized, who can also assess the quality of the information contained, as well as the potential errors in diagnosis or in the therapeutics.
It is also necessary to consider the power relations of clinical professionals in health organizations. Digital technologies, cutting across processes, can create a sense of loss of power by causing changes in organizations and altering everyday dynamics. There is a certain fear of empowered patients; patients who have information on their illnesses in the palm of their hand that they traditionally did not have, and the ability to challenge the clinician’s opinions.
Patients are becoming less patient
Comparison of traditional and digital health based medical practices
Table: The differences between traditional and modern healthcare following digital health transformation
| Traditional medicine
|| Modern medicine
| Point-of-care is the clinic or lab
|| Point-of-care is the patient
| Based on populations
|| Based on the individual
| Prescriptions and orders
| Data owned by institutions
|| Data owned and shared by the patient
| Individual experience dominates
|| Limitless data analyses
| Physicians as authority
|| Physicians as guides
| Ivory tower
|| Social media
|| Costs driven down by Moore’s law
Source : Digital health is a cultural transformation of traditional healthcare (2)
No one patient is the same
We cannot talk about patients in general. There are different segments, cultures, approach to sickness, social state, economy, etc., nevertheless the illnesses are similar. The good news is Internet penetration is a total of 3,891,683,451 users globally at the time of writing(4), with 85% and 95% of Europe and North America connected (5).
That means citizens are familiar with digital tools. In US 64 percent of smartphone owners use their phone to look up health information (Pew) (6)
There is still not enough information about the opinion of patients about using digital technologies. Health literacy is in general very low. Much controversy still exists as to what constitutes ‘health literacy’, how to measure it, and what methods are most effective and cost-effective in modifying health literacy levels.
According to the Institute of Medicine (IOM)(7), health literacy results from the interaction of individuals with the social and informational demands of the health contexts in their environment, which could include health care contexts, public health contexts health promotion contexts or chronic disease management contexts. While they appear to focus on the individual, the members of the IOM committee agreed that health literacy is, “…based on the interaction of the individual's skills with health contexts … the health care system, the education system, and broad social and cultural factors at home, at work, and in the community (8)
In a way, if there is not enough health literacy it could be difficult to move to a digital literacy in health for patients! In any case, there is a lot to do to enhance patient digital capabilities and skills. Some research has found challenges with patient using Health apps for a long period of time motivation can fall easily, and stops completely when the interface with the patient is not enough user friendly. This is one of the main challenges for software and applications developers, to have in mind a variety of potential users.
Data protection and Privacy is one of the areas where is needed a lot of work to give confidence to users. News about breaches in security or misuse of data like Facebook, does not help. Most of the wellness and health apps don’t disclose where the data is stored, or how to retrieve data if the user decides to change to another provider.
Train in vain
Who has to train patients when they are using digital solutions, like remote monitoring? In the traditional industries innovation, the companies providing medical devices or new medicines are in charge of training the clinicians, and usually the physician trains or explains “how to use” to the patient. The training model of digital is going to be quite different, there are some hints already, but still there are a lot to do.
Where there’s a will there’s a way. Perhaps we can take some inspiration from Leonardo Da Vinci on how we can overcome the challenges in front of us… (9)
- Cambridge University Press 978-1-107-01136-6 — The Systems View of Life Fritjof Capra , Pier Luigi Luisi Excerpt More Information © in this web service Cambridge University Press www.cambridge.org Introduction: paradigms in science and society
- Digital health is a cultural transformation of traditional healthcare. Mhealth. 2017; 3: 38.Published online 2017 Sep 14. doi: 10.21037/mhealth.2017.08.07
Institute of Medicine. Washington, DC: National Academies Press; 2004. Health Literacy: A Prescription to End Confusion
Parker, R., & Kindig, D. (2006). Beyond the Institute of Medicine Health Literacy Report: Are the Recommendations Being Taken Seriously? J Gen Intern Med, 21(8): 891–892
- How to Think Like Leonardo da Vinci