Not in Kansas Anymore
What will the “new normal” really mean for digital medicine?
There’s no doubt that the COVID-19 pandemic has hastened digital transformation across the board. Among the changes of the past year is a leap in the use of telemedicine, preparing the way for far more transformative digital health technologies that are just starting to come to maturity. As with most pandemic-induced change, what we are seeing is an acceleration of long-developing trends, not a sudden revolution. Don’t expect that doctors will make way for robots anytime soon – but do expect technology to start to augment the health care practitioner’s toolkit and expand their presence into patients’ daily lives.
“The year when everything changed”. “Paradigm-shifting”. “The way we see the world is different”. “Once in a century event”. Thus has 2020 been described - and those are just comments from the more sober end of the media.
So, what comes next? What has really changed? And how will those big changes play out over time? It seems as though every consultancy, thought-leader and commenter has a vision of what the “new normal” will be. In fact, we are probably a long way from appreciating the mid to long term social, political and economic impacts of the pandemic. But whatever the case, there can be no doubt that 2020 ushered in new habits that are likely here to stay.
For a start, digital commerce tightened its grip. That Amazon announced record sales and profits in geographies already well-used to buying online is no surprise. But in Latin America, traditionally more mistrustful of e-commerce, Mercado Libre doubled its user base in the third quarter of 2020, and close to doubled its revenues. Meanwhile Zoom, until last year the preserve of early adopters looking for an alternative to Skype, became a household name, the go-to tool for remote working, schooling and even socializing.
Perhaps one of the clearest – and potentially long-term – changes, is that the perennial promise of the home office finally became a reality, with even the most recalcitrant employers forced to start connecting with their knowledge and office-based workers remotely, practically overnight. Some organizations have managed this transition better than others, and the jury is still out on how remote working impacts productivity and creativity. Working from home has supporters and detractors among both employers – for every Pinterest, which recently paid $90m to end a new lease obligation on office space, there is a Facebook, which in the same month took out a new lease on an office in Manhattan - and employees – while many prefer working from home, a lack of dedicated space, the difficulty of ending the working day, and the (principally pandemic-related) issue of constant interruptions from housebound children, means that the office is preferred by others.
As is the case with much pandemic-related change, this development did not come out of the blue, but rather boosted what was a very gradual development to necessity-induced warp speed. The share of Americans primarily working from home had already been climbing, slowly but steadily, from below 1% of full-time employees in 1980 to 3% in 2017 - a figure that doesn’t include the now nearly 30% who work for themselves.
The likely medium and long-term change is also probably more subtle. While some are imagining apocalyptically empty city centers and teams that have never met in person, current opinion suggests that the most likely way forward in the medium term will be a hybrid of onsite and home working, reducing unnecessary travel but encouraging regular innovation-boosting in-person encounters.
Another digital promise which seems finally to be being fulfilled, spurred on by the pandemic, is that of digital health. In spite of the appearance of a glut of health-related mobile applications over the last few years and the rapid advance of wearable technology designed to measure every aspect of lifestyle and condition, healthcare has often seemed stuck in the analogue age. As a case in point, The Economist notes that 70% of US hospitals still post and fax physical patient records. All the whizzy technology of the last years has yet to make a real impact on healthcare effectiveness.
If you believe that stock market hype is a reliable indicator of what’s to come, you would bet that this is about to change. The research company CB Insights notes that $8.4bn of equity funding flowed into privately-owned digital health companies in the third quarter of 2020, more than double the previous year. Various high profile digital health IPOs last year included the telemedicine company AmWell, benefits navigation platform Accolade and Nanox, a digital X-ray system. Teladoc acquired the chronic disease management application Livongo for $18.5bn.
Again, a slightly more sober eye is required to assess the size of the change. Certainly, the pandemic has provided a boost to adoption of digital health solutions. Shelter in place orders and overloaded hospitals and care facilities generated a need for new ways of dealing with patients. Most obviously, telemedicine was finally accepted as a serious alternative to in-person visits. Research published in the Journal of the American Medical Association revealed that during the initial lockdown, telemedicine visits increased by 30 times, and that telemedicine offset two-thirds of the decline in in-person visits. The French telemedicine company Doctolib claims that its video consultations in Europe rose from 1,000 to 100,000 a day during 2020. A McKinsey survey of US-based physicians discovered that mid 2020, 64% viewed telehealth more favorably than before the pandemic, and 57% felt more comfortable with providing it.
The pandemic has driven enthusiasm on the patient side too. The percentage of US consumers who saw a doctor or sought medical help online rose almost fourfold between the end of 2019 and May 2020. There were also important rises in those who managed prescription medicines online and used some kind of healthcare app. 60% of early adopters and 40% of late adopters say that the pandemic caused them to buy or try a technology they hadn’t used before. A McKinsey survey carried out in May 2020 showed a shift from an 11% use of telehealth pre-pandemic to fully 76% of patients interested in using telehealth going forward.
In Latin America there is a similar story. In Brazil regulatory issues significantly reduced opportunities for telemedicine before the pandemic; once the legal situation changed patients took advantage. Teladoc reports receiving 7,000 daily visits from Brazil, TopMed 4,000; while the Albert Einstein hospital in Sao Paolo quintupled the number of doctors dedicated to telehealth to 500 due to demand. In Argentina, the private health insurance provider OSDE claims that patient acceptation of telemedicine rose from 16% pre-pandemic to 88% mid- 2020.
The question is, will this continue once in-person consultations become a more feasible option? As with remote working, there are opinions at both extremes: for some commenters this is the trumpet-call of a future where technology becomes more important than the health-care practitioner themselves; for others, it is just a matter of time before we return to “business as usual”. And as with remote working, the medium term impact is likely to be more nuanced. Of the physicians questioned in the McKinsey survey, only 29% believed that they could be as effective using telehealth as using in-person visits. They expected to have more consultations by telehealth channels post-COVID, but not by much – 10% of all consultations, a rise of 700bp from before the pandemic. However, they note that it will depend on the type of consultation required. For example, they estimated using telemedicine for 16% of new patient visits that don’t require a physical exam, and 21% of follow-up visits, compared to 4 and 3% pre-pandemic.
This assessment by doctors probably brings us closer to the post-COVID “new normal” than the sky-high tech share prices or media hype. While telemedicine presents a useful tool for doctors and often a time-saver for patients, it will not and cannot completely replace the health care practitioner. In the medium term at least, we are most likely to find a hybrid model, in which telemedicine and in-person consultations coexist, each used for the most appropriate occasion.
An increase in the use of telemedicine was able to fulfil a very real need because the technology was in place and ready to be used, and because the move towards telehealth was already, if sluggishly, underway (an American Medical Association survey noted that use of telemedicine doubled among US physicians between 2016 and 2019, to 28%). But it is really just the spearhead, the element of digital health that fits most easily into current medical practices and cultural and social norms. It is arguably what is coming up behind it that is far more interesting, and far more transformative. Digital health includes a deluge of products and services, including mobile applications, continuous monitoring, doctor-patient connectivity, AI based decision making tools, and in the best cases, ecosystems that connect all of these to provide integral disease management. And given how the pandemic has hastened adoption of maturing technologies across sectors, patient acceptance of sophisticated digital therapeutics may not be that far behind that of telemedicine.
Certainly some of these newer technologies found fertile ground for trialing during 2020. For example, in the UK, the National Health Service’s digital transformation arm NHSx sped up its trials of remote monitoring as a way of delivering care at home to avoid patients with long term conditions needing to visit hospitals. In London, a monitoring system that was being set up for high-risk diabetes patients shifted its focus to monitoring patients with COVID symptoms, to enable physicians to react faster and manage hospital capacity more effectively. This “virtual hospital ward” was subsequently copied across the country.
It’s just a small example, but it’s illustrative. One of the reasons why the really clever aspects of digital health have yet to make an impact, is that healthcare systems aren’t set up to work with them. There is no point in collecting continuous data from thousands of patients if that data can’t be easily turned into clear information that can be shared with healthcare practitioners to help them make a decision. And yes, you read that correctly: in this brave new world, the doctor is still very much front and center, but now armed with vastly superior information and new tools to improve the care that they provide to patients.
Just as digital health comes of age in terms of the maturity of the technology it uses, the pandemic may have given it the boost that it needs, by making both physicians and patients more open to its use, and even accelerating innovation in the massive and complex healthcare systems of which they form part. As is the case for remote working and telemedicine, 2020 may have provided the catalyst that will make more advanced digital health technologies part of the “new normal”. But like these new ways of working, we are more likely to see a hybrid approach that combines the power of data collection, mining and engineering with the expertise, experience and patient support provided by medical workers. The robots aren’t taking over yet. But 2020 may have been the year that helped hasten the adoption of digital health solutions. And that is good for patients and doctors alike.