I wrote this piece to try and score a job in digital health…didn’t get the job…
The South Australian Government recently announced that the new Royal Adelaide Hospital (nRAH) will open on 5 September 2017. The announcement comes after a series of delays and contractual disputes that have postponed the hospital’s opening by almost 18 months.
The nRAH will open with much fanfare. According to architectural data company Emporis, the $2.3 billion+ nRAH is Australia’s most expensive building, its construction represents the largest ever capital project undertaken in South Australia, and it is reportedly the third most expensive building in the entire world. Designed with the future in mind, the new hospital will use robotics to deliver food and equipment around the hospital.
Despite being a futuristic and world-class facility, the head of SA Health, Vickie Kaminski, revealed on the ABC last week that the new hospital won’t deliver sufficient capacity to cater for the expected demand for inpatient appointments, which numbers around 375,000 per year.
Indeed, the new inpatient facilities at the nRAH have been deemed ‘woefully inadequate and not fit for purpose’ by the 14 departmental heads at the current Royal Adelaide Hospital. It is expected that 10% of inpatient appointments will need to occur at other facilities.
These revelations come at a challenging juncture for public health in South Australia – in recent times there have been metropolitan and regional hospital closures and a scaling back of services (eg. Keith, Modbury); there have been capacity problems at metropolitan emergency departments with ambulance ‘ramping’ occurring frequently (eg. Flinders Medical Centre); and there have been a number of very public scandals relating to the mistreatment of patients (eg. Oakden Older Persons Mental Health facility) and clinical malpractice (eg. the chemotherapy bungle of late 2016) .
The fact is that the opening of the new hospital will bring no respite for SA Health.
Indeed, the pressure will continue to build as demand for medical services increases in coming years.
According to SA Health’s Transforming Health program, South Australia has one of the oldest populations in Australia, with one in six people over the age of 65. On average, 40 percent of patients in SA hospitals are between 65 and 85 years of age.
As our state population continues to age and live longer, the prevalence of chronic conditions will increase, and whilst hospitals were historically designed to handle acute medical crises, such as heart attacks, they have increasingly been required to deal with people who have enduring and complex health requirements.
At the same time, medical costs are rising sharply. South Australia currently spends 31.5 percent of its state budget on health, but at current growth rates, South Australia’s spending on health will consume nearly half of the state budget over the next 15 years.
Quite simply, our health system—if it continues to operate as it does today—will not be able to cope with the demands of the future.
Thankfully, we appear to be on the verge of a digital revolution in the health industry that promises to shift the burden of service delivery from the traditional reactive, episodic and supply-side driven model; to a more proactive, participatory and patient-driven model. The disruptive forces that have already precipitated significant change in industries such as retail, media and banking are now starting to take hold in the health industry and this may ease some of the pressure on public health.
These forces for change are driven principally by the elevation of the place of the ‘consumer’ in the service delivery transaction. Consumers of today are empowered, they are well-informed, they have clear wants and desires, and they have immediate access to a host of options that were previously not open to them. Through greater awareness of health issues, consumers have sought to take a more active role in their own health care, thus challenging the old paternalistic model of the doctor unilaterally prescribing the best course of action for the patient. This new paradigm in health care is known in medical circles as ‘participatory health’, where ‘e-patients are empowered, engaged, equipped, enabled’.
The contemporary symbol of consumer empowerment, and a cornerstone of ‘participatory health’, is the internet-enabled smartphone. Today, these handheld devices are ubiquitous (84% of Australians have one); they are rarely found outside the reach of the consumer (14.6 million Australians use a mobile phone daily); and they now represent the world’s preferred mechanism for accessing the internet (mobile connections now outnumber desktop connections). With all of their converged capabilities—internet, social media, camera, biometric recognition, WIFI, Bluetooth, near-field communications, GPS—the smartphone enables consumers to obtain information instantaneously, to communicate and share content in real-time, to research and inform purchasing decisions. The smartphone has put unprecedented power in the hands of the consumer.
An extension of the smartphone that is powering the personal health revolution is the emergence of ‘wearable’ devices. Many of us are already equipped with Fitbits and Garmin watches that measure and record our daily steps, heart rate, vertical climbs, calories burnt and distance covered. These wearable devices send and receive data from other connected components of our digital lives: smartphones and other personal devices; fitness apps like MyFitnessPal; Bluetooth-enabled bathroom scales; online communities such as Strava; and everyday social media profiles such as Facebook and Twitter.
Whilst fitness wearables as a consumer technology are still embryonic and the ‘jury is out’ on their accuracy in many quarters, they are symptomatic of our society adopting a more active role in health care and personal wellbeing. As that trend continues to grow, I wonder whether a proactive, forward-thinking government might consider putting one of these devices on the wrists of every school child in its jurisdiction?
Consider the benefit of providing a free Garmin watch to every school student entering Year 5. Paired with a school tablet or laptop, the watches could be used by students to measure their daily physical activity. Individual activity could be policed by teachers in the same way that homework is now, with every student required to undertake at least 30 minutes of physical activity in a 24-hour period (recess and lunchtimes could contribute to this period of activity). In the classroom, the results of monitoring could be shared electronically on a ‘league table’ and used as a competitive spur, as well as providing a great focus for the study of mathematics in class. More broadly, classrooms, year groups and whole schools could compete against each other to become the ‘most active’. Such a bold initiative (and, granted, an expensive one) would create enduring awareness and help alleviate the highly-publicised problem of childhood obesity, an issue which is destined to cause a significant burden on our health system in future years. Some might suggest that monitoring childrens’ physical activity is draconian, but it is probably no more so than standardised NAPLAN testing.
‘Wearables’ are one thing, but as the miniaturisation of devices continues, a natural progression will see the mainstream emergence of ‘embeddables’ or ‘implantables’: small chips or devices that are inserted into the body—perhaps under the skin like a dog’s microchip —for the purpose of monitoring key health indicators and storing medical information.
Consider a smartphone app that monitors, records and troubleshoots all of your body’s health indicators using embedded sensors and behavioural analytics drawn from your everyday smartphone activity. Blood pressure. Cholesterol. Body temperature. Hormone levels. Blood alcohol level. State of mind. Mood.
Now imagine holding all of your personal medical records on a single microchip beneath the skin, backed up to a personal ‘cloud’, with the information only accessible using a fingerprint impression or retina scan. No need to carry those oversized envelopes full of X-rays and ultrasound scans between your GP and specialist!
Whilst this might seem like something out of a futuristic movie such as The Minority Report, it’s not too far away from becoming a reality, particularly when you consider that we already embed pacemakers into people’s hearts to control heart rhythm.
As personal sensors get more accurate and authoritative (whether they are worn or implanted), the possibilities for self-diagnosis and remote information sharing with medical professionals becomes a possibility. The traditional health model requires that the patient and the doctor are in the same room during diagnosis, but the advent of reliable sensors may, in many cases, preclude the requirement for a face-to-face appointment altogether.
For example, symptoms of the common cold could be diagnosed by personal sensors, with advice delivered electronically to the patient on how to treat the condition. Rather than clogging doctor’s waiting rooms with minor conditions, and the health system incurring the opportunity cost of treating frivolous cases, these patients could self-diagnose and self-treat based on the advice provided by email or SMS message.
If an audience with the doctor is required, it could be achieved initially via a remote telehealth or video-conferencing channel – these are much more efficient than physical appointments. These services are already being used to good effect for patients in far-flung rural locations, but there is no reason why this model couldn’t be used more widely in metropolitan areas, particularly for routine home monitoring of chronic disease and outpatient services. The spread of high-speed fixed internet via the NBN into the suburbs and beyond will enable this service.
Should more urgent attention be required, personal sensor data could be used to auto-triage the patient ahead of their arrival at a medical facility. Third parties can also be included in the information sharing mix, facilitating the speedy provision of information between primary, secondary and tertiary medical providers, and to family members, carers and insurance companies. All of these measures improve the efficiency and effectiveness of the passage of information around the medical system, resulting in substantial productivity savings.
Collectively, the ‘big data’ generated by personal sensors has great potential to provide detailed insights into wider community health, to determine the prevalence and spread of disease, and to assist with medical research. By manipulating this vast amount of data, machine learning and artificial intelligence will, in time, allow us to predict forthcoming medical epidemics, identify root causes, and apply preventive measures in advance, ultimately easing the burden on the health system.
Whilst some these technologies might still be some time off, there are relatively simple measures that can undertaken right now to improve the efficiency and effectiveness of the health system through the application of digital technology.
The customer experience at the local GP surgery is perhaps indicative of this: we’ve all been subject to frustrating delays in a GP’s waiting room, surrounded by wheezing pensioners and a stack of three-year old New Idea magazines. In many cases, the implementation of an online appointment/resource booking system can go a long way to removing the productivity drain that GP waiting rooms create. These systems allow self-booking and management of appointments via a web interface; the management of waitlists and cancellations; and patient alerts when delays are experienced.
Consider how such a system might improve the delivery of elective surgery in South Australia. According to SA Health, 25% of all elective surgery procedures are cancelled (many due to the unavailability of theatres and beds), and day procedures make up only 52% of all surgery (compared to an average of 60-70% in other Australian states).
It is clear that the South Australian health system is under considerable stress and, despite the fact that we will shortly have a new hospital, there is no relief in sight. Our population continues to age and the demand for chronic medical services continues to grow. Whilst there are no short term fixes to this problem, a longer-term approach that shifts the conception of health care as a purely episodic and reactive service, towards a more proactive, participatory and technology-enabled model, may help to ease demands on the health system in future. Faced with mounting criticism over present-day health care deficiencies, it will take a bold State Government to put in place the foundations of this paradigm shift.