Digital Health : Making the penny drop....

Why is there so much talk about the potential of digital health and so little tangible benefit to those it aims to serve?

The Sexiness-Quotient of Digital Health is at an all-time high.

It is the easiest way to look knowledgeable in any agglomeration -social or business - by talking about Technology in Healthcare. Perhaps, because health is so personal and yet so impersonal.

?The Media in the Western Countries, The FAANG companies, Universities and IT powerhouses continue to add grist to the mill with exotic discussions on AI, ML, IoMT, SaMD, Robotics, Personalised/Precision Medicine and so on to sell the next conference. They have a robust business case to explore the edges, and appear like thought leaders to maintain business in several domains, except the one that matters directly here ie. Healthcare Outcomes. The west has not achieved anything great in Digital Health yet. Just look at their Public Health outcomes vis-à-vis their maturity as economies and technology innovators.

?It has however brought dramatic visibility to event managers and the usual suspects on the speaking circuits.

The revelry continues to gather pace even – and this is the real danger - in the global south, which has a different set of challenges to solve but is busy preening on the hand-me-downs from the global hotpot.

All of this is not meant to dissuade us or water down the potential and promise of digital health. Its potential to deliver scale, equity, safety and sustainability of healthcare and fuel innovation that will keep the larger magnitude of humanity healthy is HUGE and life transforming – both for humans and the biosphere. A healthy and productive individual – particularly a mentally, socially and spiritually healthy human being is what potentially will save our biosphere from the unfolding disaster. If anything therefore, we in the Global South, have a far-far greater stake in doing it right and adopting it faster for the billions who are still waiting for care.

?Universal Healthcare aims to do just that. The lack of adoption of Digital Health at the delivery side, prevents Quality, Quantity and Authenticity (Contextuality) of data from being made available.- Such data is foundational to make universal healthcare possible, across the private and public divide.

?Let us understand the above through 3 indisputable facts.

Without such data being available – Universal Healthcare cannot be a reality at scale.? The costs – both financial and in resources – is essentially unsustainable.

Without Adoption of ‘Proper’ Digital Health Systems at scale – such data cannot be available in sufficient quantity, quality and context.

?Ergo – Without Digital Health at scale, there can be no Universal Healthcare, no Integrated Healthcare, no One Health etc etc.

?It’s that simple!

Why, therefore, with all the above ‘self-evident’ and ‘objectively’ agreed upon facts is Digital Health still treated as an orphan and pariah across both? the Technology and Health Sectors?? It’s quite staggering to contemplate.

Firstly, Healthcare, unlike most other domains is less ‘Coherent’ than other more fungible pursuits like Banking, Finance, Travel, Retail etc. In these ‘man made’ sectors,? the greater objectivity in decision making, the greater ‘standardization’ capability? and? the small number of transaction archetypes make it easy to deploy digital solutions at scale. Clinical decisions in healthcare on the other hand, bring a very large ‘subjective’, ‘customized’ and ‘individual’ point of view to the table - where the final goal we seek to evolve to is the ideal of personalised medicine!!.

?Secondly, It is probably more appropriate to compare Healthcare to an Organism than an Ecosystem. Ecosystems are more finite in nature and predictable in their behaviour; given that the alignment of incentives is far simpler compared to Organisms that are adaptive and evolving. The fact that the world now talks of determinants of health to be addressed by ‘One Health’ and ‘Integrated Health’ approaches, are clear (though not easily understood) admissions of this complexity. It is futile to see healthcare as public or private anymore since interoperability between all its elements is critical to this organism. All Health is? Public Health.

?Thirdly, care is a life course endeavour and the needs of a beneficiary change with age and stage. There is a need to be mindful of Healthcare not being an episodic pursuit, in order to make it sustainable and contain both Out of Pocket and Public Expenditures on health while improving outcomes and indices.

?Can we then afford the luxury of ignoring ground-up adoption, at scale, of digital health; and fiddle like the proverbial Nero while lives are driven asunder by illness and lack of care? Or hide behind more sophisticated excuses like a federated polity, policy issues, infrastructure challenges and so on?. How is it that a child in a village is able to play an online game on a phone, but we aren’t able to offer triage-on-tap? Is there a problem of priorities here? Are these problems a product of conflicting incentives? Doesn’t Healthcare deserve a greater sense of urgency and some degree of enlightenment of self-interest ? These are questions each one of us connected to healthcare must ask ourselves.

?Given the peculiarities of healthcare discussed earlier; Digital Health can only be adopted successfully when it manages to create interoperability amongst stakeholders that is unambiguous (semantic), near-real-time. A balance between universalisation and localisation needs to achieved. This would require a minimal and inclusive approach to bridge across the diversity and complexity that pervades the sector. The National Digital Health Blueprint in India is a reference architecture that does just that, very elegantly.

Let’s revert back to understanding this without any embellishment.?

Without Digital Health at scale, there can be no Universal Healthcare,

How then do we SCALE Digital Health rapidly in the Global South?

Can private, commercial based, existing ‘ring fencing’ strategic initiatives do the job? Maybe yes – in a timescale of decades or centuries maybe.?

?Can an evolutionary approach through an ‘explosive’ crystallization of creation of Digital Health systems work?? Possibly yes – and in a MUCH shorter time frame.

?Therefore - A true Opensource approach through the Elastic Cloud is the only possible way to accomplish that equitably, and without making it burdensome to stakeholders.

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However, that requires following not just the letter but also the opensource spirit. And herein lies the rub.

As we have witnessed, commercial interests - overt and covert - ?seek opportunities to build tollgates and exclusion mechanisms in opensource environments very often, by sheer heft and hustle across forums and governance; or taking advantage of the lack of transparency in the early stages of the games, creating ‘Cathedral’ models with unfair power structures instead of transparent standards and rules based ‘Bazaar’ like models. Bazaar models operate on level playing fields and unhindered innovation that lets many players compete. The user benefits from this balance between universalization and localization with higher service levels and is secure from vendor lock-ins and obsolescence due to continuous innovation.

?Linux, Java, Mozilla Firefox, Apache and GNU are great examples of Opensource Innovation for a common good, and the power of enlightened, collaborative ecosystems. Healthcare critically needs this given its profound connection with quality of life

?All the higher seductive benefits of exotic technologies that are being evangelised depend on the wide and successful adoption of digital health, regardless of the narratives that are built on vested interest.

?The lack of quality and quantum of near-real-time data will not let any of these exotic technologies translate into anything more than a Proof-of-Concept to be showcased, much less deliver their full benefit to mankind.

?So what will make the penny drop ?

?A combination of committed governance and administrations that put public good above politics or tardiness; some large hearted philanthropy; a few enlightened business interests who have the ability to rise above transactional considerations and immediate gratification; and then of course Healthcare Professionals and Providers who can embrace change with the understanding that they are part of a much larger whole, called public health.

?The onus of public health lies squarely with governance and administrations who will clearly have to rise above political quibbles and ensure that they can firstly prioritize the larger good for people and secondly ensure a level playing field for a ‘Bazaar’ model of innovation in digital health to emerge, avoiding the temptation of quick fixes.

?There is then, also the structural incoherence in governance that is pervasive. The Ministries of Health are usually loathe to look beyond the legacy of program driven approaches. They tend to address digital transformations by creating a special silo to deal with it. These surrogates are toothless without a mandate to create the state/filed level structure to follow through and so adoption never happens in the real sense. To compound the problem is the lack of a clearly defined responsibility for digital health, then burdened by the lack of cross domain skills at all levels resulting in a lack of inherent translational ability to generate outcomes from these grand plans.

?It is not unusual to see boards and ministries with no clinical professionals in any position of consequence, much less people with cross domain expertise.

?Philanthropy will need to step in to support frugal innovation and ensure persistent support is available to opensource communities to stay truly open, until a fair and open innovation ecosystem takes root. It will take far lesser sums of money than imagined, given the change in technology has obviated the need for infrastructure heavy investments in this space. Digital Health is about leveraging existing infrastructure and hardware.

?Some enlightened business interests are also needed, that can see beyond the paradigms that they are already invested in, and are willing to build profitable businesses based on opensource innovation and embrace the transformation of business models that comes with it. Interestingly, and this is ironic in the context of digital health, most business leadership conferences evangelise transformation ardently.

?Lastly the user of these technologies ie. the healthcare professional, will have to give up the lone-ranger approach to healthcare for the greater good.

?For all stakeholders there is much to unlearn and lots to learn anew.

?Our willingness to make that change and walk our talk, may be essentially a test of our humanity and our capability for compassion.

?The price of failure is frightening to contemplate.

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