The following is the text of a talk “Why Digital Technology Might be our Best Ally Rather than our Worst Enemy” given at London’s Olympia by Mark Brown as part of UK e-health week 2016.
Today I’ve been given the job of talking to you about why digital technology might not be our worst enemy in health and care and why it might, in fact, be our best ally.
What I want to do is make the case for certain ways of approaching e-health technology by first looking at reasons why it can be difficult to engage with the idea of digital tech; then looking at some of the things digital tech might do in health and care then finishing off with some ideas about what you might do to help a good e-health future happen rather than an awful one.
Generally speaking, the promise of e-health is that it can make things happen in different ways. In my view, we’ve reached, at least for the time being, the end of the era of big breakthroughs in health. A lot of people need things they currently aren’t getting. We’re stuck with the treatments we have, many of the structures we have. I think the area where our advances will be made, at least in the short term, are in the sweating of what we do have; continuing to explore new ways of making a bigger impact.
In social care and in health care, the single most valuable resource is people. If we get tech in health and care right it could free up more staff time to do the really important things that only humans can do. Tech needs to make things easier and better in ways that work for people. For example, digital technology might be able to reduce the burden of paperwork meaning we could spend more time with people.
So, why do people worry about tech? Why does it look sometimes like more of an enemy than a friend?
Best case scenario / worst case scenario
It will not have escaped your attention that the NHS in England is going through what, to the mind of some commentators, is its longest ever time of crisis.
The picture in social care is similar. Local authority budgets are being squeezed until their pips squeak. The money that was there to pay for things isn’t there anymore.
The first flickerings of austerity began during the global financial crisis in 2008. As banks collapsed and debt became toxic; money just evaporated from the economy. It became clear that public spending wasn’t going to be able to expand indefinitely as it had for much of the previous decade.
Whatever your view, the story is the same: there’s less money in the kitty than we’d like and any of us who work in health or social care have to find ways of being more efficient.
At the same time, something incredible was happening. While the global economy went into meltdown and the UK government desperately attempted to avoid us going bust; almost without many of us noticing, the boundaries of what was possible with digital technology began to widen.
The iPhone was released on June 29, 2007 in the United States. The first commercially available smartphone running Android was released at the end of 2008 in the US. The first iPad was released on April 3, 2010, with Android and Windows tablets following soon after.
Digital technology was becoming mobile and, as importantly, it was plummeting in price.
At the same time that it was looking like we were going to hell in a handcart with socks darned so much they were all thread and no wool; a brave new digital future was unfolding. While people are cuing for the food banks we’re uploading selfies like there’s no tomorrow. The credit crunch was happening at the same time as we all started to fall for Candy Crush. What if, the question seemed to be, this digital thing might be the answer to our public service problems?
And there we hit our first snag. At the same time as trusts and local authorities were preemptively trying to slash their budgets (2008-2010) and then government were reorganising and cutting (or not cutting depending on your political viewpoint), this flower of digital possibility was blooming. For many, the idea of efficiency savings, of working smarter, of pushing for better outcomes, of doing more for less become a codeword for cuts, erosion of duties, unmet need and greater job insecurity. The choice looked like either maintaining everything that we had before, health capacity being about warm human bodies or about embracing the digital future and having empty rooms filled with bleeping screens. Digital transformation looked like a code word for ‘loss of jobs’. People still ask: why are you farting on with technology and spending all that money instead of employing more nurses or other frontline staff?
‘Unleashing the power of e-health’ runs right into this. The easiest way to avoid the implications of tech is to do everything you can to avoid using it. There’s sometimes an idea, one at times unfortunately propagated by telehealth providers, that technology will allow you to ‘do away’ with staff teams. Andrew McAfee Co-author of The Second Machine Age refers to this as digital encroachment, the direct replacement of human labour with machine labour.
For almost as long as the NHS has existed we’ve all watched digital technologies make other people’s jobs obsolete. Remember typing pools? Or indeed bookshops?
I think there’s four challenges in embracing digital in health. Our first challenge in thinking about digital technology as an ally is that we fear it might take away our job. It’s a myth that all human endeavours are equally likely to be completely disrupted by digital encroachment. Some things will always need direct human labour. Health care is one of those things. Nursing especially. Nursing and midwifery are primarily at their heart about doing things with people and the construction of systems, processes and knowledge to enable that to happen in the best possible way.
There’s a second challenge in the sense in which, for some people, the use of digital technology in healthcare feels antithetical to NHS values. This is especially true if you see the job of the NHS is to care for people not in an abstract sense but in a real skin to skin, face-to-face sense. It can feel as if the potential of technology to remove the human work from a lot of tasks makes people very scared that this will be pushed to a limit, as if the strongest voice is the one pushing for no humans at all.
The truth is that some patients want far more contact with lovely NHS staff and some want far, far less. People tend to have a preference for the level of face-to-face care that’s comfortable for them. There are times when I absolutely would love to talk to someone about my healthcare but I have no reason to make an appointment and other times where I have to go to the doctor for a routine procedure when I’d much rather be somewhere else. Digital might provide a way of getting that balance right for more people.
Our third challenge in thinking and dealing with the idea of new technology is that it makes us feel out of our depth. It challenges us by making our workplace practice unfamiliar.
We have spent years training to be what we are. We’ve spent time and money and blood and sweat and tears building our professional toolkit; turning ourselves into useful tools. Our job is what we spend most of our time doing. We worry about having that professional competency undermined or taken away from us.
New technology feels like magic, something arcane, something only controlled by other people, not us. It feel like something built by people very different to us. Science fiction writer Arthur C. Clarke, writer of 2001 amongst other things, back in 1963 wrote “Any sufficiently advanced technology is indistinguishable from magic.”
Our fourth challenge is that we are scared that we don’t understand tech or that we’ll be helpless if it breaks.
This can be disconcerting if you grew up, as I did, in the age before apps and smart phones and ipads. Then computers were something you had to learn; like learning a new language. The computer was like a foreign exchange student that sat in the corner, not understanding most of what was being said and only leaping into action when exactly the right command was issued in exactly the right language for it to understand.
To be fair these fears are not unfounded. A lot of the technology rolled out by the NHS internally has been a bit rubbish. When that happens we fall back upon the ways we have ‘always’ done things. Internally in the NHS and in the wider world of social care, the ‘ring round’ is often the way in which tasks are achieved ‘in real time’ (the traditional ring round to find a bed); with email functioning more as an analogue of letters and memos rather than as a form of instant communication. There is still a lot of ringing to check to get things done. Many wards only have one phone. There are still NHS sites where there isn’t wifi. When record keeping software isn’t very good we end up keeping hand written notes and ‘typing them up later’.
The problem of bad tech is that it makes the thing it was intended to replace look even more correct. That’s because it doesn’t solve the problems we have in a way that suits us. It’s easier to remember the times that a ‘new thing’ didn’t get the result we wanted to happen than to think back on the inefficiencies of ‘the way it has always been done’.
What we think about when we think about tech
It can be difficult to get into tech from a standing start. It feels like there are far too many things to learn about and far too many different things to try. The best thing to do is to start by thinking about what digital tech can do in health.
At the beginning of 2016, independent health charity thinktank The King’s Fund published an article listing eight digital technologies that they feel will revolutionise health and care.
The authors Cosima Gretton and Matthew Honeyman divided the article between technologies that are “on the horizon” and those “already in our pockets, our local surgeries and hospitals.”
Number one on their list was The Smartphone. Gretton and Honeyman claim that in 2015 two-thirds of Britons used them to access the internet. The smartphone is ultimately a tiny powerful computer that is very, very good at sending and receiving data and interfacing with other things. It also makes and receives phonecalls. In the main, though, the smartphone is an amazing thing for health because, unlike just about every other health intervention, people love their phones, value them, look after them and carry them around with them at all times without being asked.
Other entries on their list included:
Something they call ‘At-home portable diagnostics’, the use of particular bits of kit either on their own or in conjunction with other devices like smartphones to provide diagnostics, readings or measurements and that help professionals and patients to interpret the results. A familiar example of this will be things like blood glucose monitors for diabetes.
The authors also included smart assistive technologies in this category. Lots of people use devices and apps to help them to do things they want or need to do. With addition of sensors and ways of communicating the data they produce; these things – from adapted cutlery to walking sticks can track how they’re used over time – hopefully feed back lots of useful information about how, when and where they’re used. It’s not always clear whether people will want their walking stick grassing them up to their medical professional for not going for a walk or their inhaler telling their doctor when they’ve had a cheeky fag.
Also on the King’s Fund list were digital therapeutics. These are health or social care interventions delivered wholly or mostly on computers, tablets or smartphones. Mental health, my own area, is rife with these interventions. Everyone is trying to crack the model for delivering evidence based psychological therapies at scale using digital devices. To my mind no one has quite managed it yet. Probably of more interest is the use of such apps or services to support people in the management of long term conditions, where a combination of health positive activity needs to be sustained over time and to be reviewed.
They also included machine learning. If you’ve ever used the google search engine you’ll have noticed that over the last few years it’s gotten better at guessing what it is that you’re searching for or what you’re asking it to do. This is because google is learning from the inputs of people who use it. Machine learning is about programs that are set-up to process data and to find things in that data they haven’t been specifically asked to discover. Machine learning means that programs used to recognise things can begin to spot new patterns not obvious to human observers or to make suggestions about new things that it is shown based on previous things it has seen. The implication is that if we have programs that look at data for patterns we’ll end up with programs that can make guesses when exposed to new data. There are thoughts that this might be useful for diagnostic decisions or for analysing lots of health data.
The King’s Fund were also keen on connected communities as a big health and care impact. Given that social media and apps and services with social functions can now bring us together; Gretton and Honeyman suggest that this might be something that’s harnessed to support or create patient communities; enable peer to peer knowledge and support and to generally help stitch us together into a mutually supportive fabric that can take some of the weight of keeping as well as possible.Patients supporting patients; peers supporting peers; patients supporting professionals and so on.
If we combine Gretton and Honeyman’s list you get a glimpse of the potential for digital technology to fill in many of spaces where health and social care finds it difficult to reach, especially focusing on the bits of people’s lives which don’t take place in hospital or the consulting room.
These however are what you might call technologies. The world is full of technologies that no one knows what to do with. The key is to find the application of a technology that works for people and solves a problem that they have. We had touch screens for decades before apple arrived with the iphone and made us realise that they were really useful for things that we could hold in our hands.
Similarly, there’s lots of things that are possible it’s about working out what’s desirable.
Roughly speaking, digital tech can do the following things in health and care
Automation – basically digital can use machine power to do things that would be routine but would take person time. For example, an app could check blood test results and only bring them to attention if they are abnormal. Similarly, an app might dispense treatment advice or a device paired with an app might monitor a condition. If it’s boring, repetitive, involves the same thing over and over you can bet it’s possible to automate it. Repetitive and rote tasks are where we’re most likely to make mistakes.
Build better Interfaces – there are lots of sources of data and information in the world. Digital can make better ways of getting that information and sharing that information. Electronic patient records are an example. Another might be a way of displaying patient information in such a way as to minimise clinical mistakes. Digital technology is all about how people interact with things. Touch screens make things possible for people that were complex or impossible before. If there’s more than two things that need to interact with each other somehow, digital tech can probably make it happen better.
Communication – digital technology makes messages follow people, makes it possible to speak to multiple people in real time, makes it possible to make contact with thousands of people at once. Everything from social media to text messages to voice-to-text to text-to-voice to handwriting recognition: there’ll be a digital way of getting the message across differently.
Data – digital technology makes it possible for something to collect data as it does the thing it was intended to do. A toilet might tell you via sensors how many times it has been used in twenty four hours, a bed might tell you how many times the patient has turned in twenty four hours. If something is happening; digital tech will probably help you find a way to measure it and give you results in a form you can use.
You’ll hear many of these ideas applied over the course of today’s presentations.
I liked very much University College London Hospital’s app ‘Find my Patient’. It’s an iOS app that “ is able to securely display a variety of imaging and pathology results, as well as locating the patient’s bed within the hospital. Hospital patients sometimes need to be moved to a different ward or area due to clinical requirements or for practical reasons. The FindMyPatient app means that doctors no longer need to locate patients using printed information from hospital terminals or by calling wards to find where their patients have been moved to.”
That feels to me like a neat little solution to an actual problem that people really have. If you can use digital to solve a problem people actually recognise in a way that works for them they’ll love you for it.
How can health and care get comfortable with the idea of tech?
The NHS is one of the most complex experiments in human healthcare ever undertaken. There are few who understand it in its entirety and it’s often baffling to even people who work within it. Social care continues to become more complex by the day. Often e-health solutions are instigated to solve system problems and it’s up to people ‘on the shop floor’ to make them work. I’d like to see it work the other way, with digital technology being used to solve shop floor problems. And that’s where you come in.
One of the first ways we can get comfortable with tech in healthcare is to just be interested. The world is full of amazing tech things. There’s more processing power in your pocket or bag then there was to put a person on the moon. The best way to get a feeling for tech is to just play with it. Instead of saying: this isn’t for me; even reading just the tech stories in the newspaper will start to bring the possibilities of digital technology alive.
The second thing is keep your eyes open for problems to be solved. In some ways; I think the most powerful partnership for influencing what technology in health and social care can be is between the frontline and patients or clients.
One of the really cool things about medical and social care people is that you tend to be problem solvers; but you don’t need to be able to make an app or a website yourself to come up with a really good problem that someone should solve. People who build tech are engineers. Engineers like solving problems. Health and care professionals know about health and care. People know about their lives and how they feel about them. The mix of those three things makes good digital things happen.
Looking toward digital in health doesn’t need to be about massive transformation; it just has be about solving a particular problem and solving it well. If we spend our time with people, people we care about, we will see problems without solutions all of the time. E-health doesn’t have to be massive. It gives us a chance to build things that might initially change the lives and health of a few people, then a few more. And then more.
Think about your daily practice: what things really get on your nerves? What things never work very well? What things do patients complain about most? Think about what things do most to take you away from the bit of your job that patients most value. The chances are you’ll be able to turn that into a question for which e-health might have an answer.
The formula I would use for thinking about digital technology and innovation is:
Knowing what kinds of cool stuff technology can do + thinking about small, well defined problems = ideas for possible digital solutions.
Sometimes the answer is a new thing. Sometimes the answer is an old thing in a new way or at a new time or in a new place. Sometimes the answer turns out not to be digital at all.
Not paying attention to digital technology doesn’t mean it won’t happen in health and care. It just means that the digital technology in health and care will be bought and built by people who understand the people sized problems of health and care less than we do. Digital technology is not a possible future, it’s an unfolding present. Digital is already changing things. A change you choose is much less painful than a change forced upon you. We have the opportunity to make the best of digital technology so that we can make the best use of ourselves, our skills and resources. That’s why need to stay at the table, get our head around the possibilities and the things people need and influence what happens.
Out there, amongst the stands and the speeches and the presentations and the celebratory editorials, it’s like Gods speaking to each other over the heads of us mere mortals. Big companies talking to big bosses. Technology will wing its way in, solve all the problems, be seamless they promise. The debate is like first world war generals discussing a map of the Somme while the rest of us are shivering in the mud of the Somme, ducking bullets and trying not to die.
Roughly speaking, tech people tend to get really excited about the application of something while the rest of us get worried about the implication of it. Or to put it another way, tech people ask ‘could we do it?’ while the rest of us ask ‘should we do it?’
At the moment; it’d be easier for google or apple or Microsoft to open a hospital than for the NHS to get fully up to speed with the possibilities of technology. I don’t want google or apple to be running my healthcare if it means the NHS won’t be here.
If we don’t stay interested, if we hide from digital, somewhere in the NHS or a local authority, miles away from the frontline, someone will come along and commission the wrong digital things for the wrong reason, doing the wrong things in the wrong way. Probably for the wrong people.
If you want to get started, get out there today and talk to people. Ask them to explain to you exactly what problem their shiny new tech solves. Ask them ‘if your technology is going to be my ally, what’s in it for me; my colleagues; my patients, my NHS, my social care?’
We have a chance to make digital something that makes healthcare better. Technology isn’t the opposite of healthcare; it’s a way for health and care to get better.
We’re making the future of the NHS and the future of social care right now and I want to make sure we do them proud.
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.