An unexpected consequence of the Covid-19 pandemic is that governments everywhere are having to rethink the role of digital technology in healthcare.
To keep people away from hospitals, for instance, the US and Australian governments have both approved reimbursement for telemedicine consultations, allowing patients to speak to doctors via video-link.
The UK government has launched a coronavirus chatbot to relieve the pressure on the National Health Service and reduce in-person contact. Experts say that such innovations will help in the longer term by reducing unnecessary use of health services that were already struggling to meet the needs of an ageing population, long before Covid-19 struck.
“The pandemic has drawn attention to the complexities of delivering healthcare within a massively decentralised market,” says Vincent Grasso, global healthcare and life sciences lead at IPsoft, an artificial intelligence company. “Part of [our] dilemma involves the inability to scale up human labour fast enough to meet new demands on resources. AI applications, including conversational computing, can be very helpful to meet this demand.”
Health agencies are also striking partnerships with tech companies at a speed and scale hard to imagine under normal circumstances. The NHS is working with the likes of Amazon, Microsoft and Palantir to create data models to optimise the allocation of ventilators, hospital beds and staff.
Data privacy restrictions are loosening. The UK Information Commissioner’s Office recently said it would be “pragmatic” in enforcing the usual rules, taking into account compelling public interest arguments. It acknowledged that organisations might fall short of their usual data protection practices due to their need to divert resources away from compliance and information governance, and might take longer to respond to information rights requests. “The ICO does not operate in isolation from matters of serious public concern,” it wrote.
The crisis has been a big impetus for enabling digital health, says Klaus Boehncke, partner at LEK Consulting, a management consulting group. Governments were already working on new rules to facilitate the emergence of digital health, ranging from apps and wearables to “digi-ceutical” therapies that rely on software as a key component in managing a disease.
Germany passed a law in November to allow doctors to prescribe health apps, with costs reimbursed by insurers. Such moves are “a driver of innovation in German healthcare”, says Ramraj Puvinathan, research associate at Public, an accelerator for public sector-focused start-ups. “It is the first model of its kind anywhere in Europe, in terms of reimbursing healthcare providers through statutory health insurance.”
Regulators are breaking down data silos to better unleash innovation in digital medicine and AI. The EU is integrating data across member states to enable cross-border digital prescriptions and patient data exchange, and the US recently passed rules to enable data to flow more seamlessly across the Medicare and Medicaid healthcare programmes.
Regulators are approving a growing number of digital health therapies. In 2017, the US Food and Drug Administration approved the first “digital pill”, a sensor-laden chemotherapy drug that allows clinicians to monitor whether patients are following their prescribed drug regimen. The FDA has also sanctioned mental health apps from Pear, a San Francisco-based technology group, that support people with addiction and chronic insomnia.
More products are expected. Apple and Johnson & Johnson are running a clinical trial exploring whether Apple Watch can be used to detect atrial fibrillation.
In Europe, the first wave of digital health start-ups has focused mainly on back-office tasks such as communications, staffing logistics and information flows. “Most successful European [digital health] start-ups are operational, and don’t classify under medical regulation categories,” says Puvinathan. “What is interesting now is a second wave of start-ups that we think will go into the ecosystem, requiring clinical evidence, ticking regulatory boxes and fulfilling European regulations.”
Clinical trials themselves could change significantly thanks to AI advances. The technology has the potential to improve logistics such as patient enrolment by quickly scanning electronic medical records and clinical trial eligibility criteria.
For instance, 86 per cent of trials do not meet enrolment deadlines, and nearly a third of Phase III trials fail because of inability to recruit patients. AI could improve the selection of participants by sifting through electronic medical records, genetic information and unstructured data, including doctors’ notes, to find the best fits between proposed therapies and disease signatures.
AI could support adaptive clinical trials, a new approach in which studies change tack based on emerging insights. “AI could help with stratifying patients and identifying new biomarkers that might be important and lead to a change in the trial,” says Clay Heskett, partner at LEK Consulting. “That has to be done with the blessing of the [regulatory] agencies, but the tools are enabling more flexibility than ever before.”
Not everyone feels comfortable about the rise of AI, digital technology and, by implication, commercial interests in healthcare. Tech companies have faced public criticism, regulatory rebukes and even legal challenges for data privacy breaches.
The UK’s privacy watchdog said in 2017 that an NHS trust had broken data protection laws when it gave DeepMind, Google’s artificial intelligence arm, access to the personal medical records of 1.6m British patients. Google and the University of Chicago faced a lawsuit over a data-sharing agreement that failed to secure patient consent, and allowed re-identification of anonymised patients, by triangulating date stamps and doctors’ notes.
Even today, despite the gravity of the coronavirus threat, UK privacy campaigners have expressed concern about the involvement of tech companies in the NHS Covid-19 response. Palantir, for instance, also has a portfolio that includes tracking undocumented migrants for the US Immigration and Customs Enforcement agency. The NHS partnership with Big Tech has prompted an open letter from a group of campaigners, doctors and academics imploring the US agency to avoid cutting ethical corners and to maintain transparency in areas such as contact tracing.
Others have noted the rise of the “bio-surveillance state”. In China and South Korea, tech companies are playing a critical role in facilitating quarantines and mobility restrictions. This includes distributing QR codes via apps that assign colour codes determining quarantine status, based on factors such as travel history, time spent in infectious areas and relationships to virus-carriers. This has prompted allegations of inaccurate ratings and stigmatisation of the ill.
The speed of China’s Covid-19 lockdown cannot easily be disentangled from a techno-surveillance infrastructure that also allows the tracking of political dissidents and minority groups.
In the west, concerns have already been raised over the increased participation of tech companies in managing hospital data. A recent report found that 33 of the 50 US-based hospitals examined were working with Amazon, Google or Microsoft, but without standardised and open rules over data protection management. Hospitals cited cyber security concerns as the reason for not sharing such details with an investigation led by STAT, a subsidiary of the Boston Globe newspaper.
In the consumer healthcare space, surreptitious data-sharing has been widespread; one review of medicine-related apps on the Android mobile platform found 79 per cent of those sampled shared user data with third parties including advertising companies, private equity firms and credit agencies.
Covid-19 has prompted an expansion of state power in healthcare that is a long way from over. These changes are helping tech companies and data innovators play a greater role in service delivery. Much will depend on whether regulators roll back the reforms once the pandemic is over.
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