What's Next for Digital Health After COVID-19?
How the pandemic has accelerated digital health, what roles wearables might have in diagnosis and what's next for long-term arrhythmia monitoring
Microsoft CEO Satya Nadella remarked earlier this year that the early months of the COVID-19 pandemic saw “two years of digital transformation in two months.” As the world moved to working, shopping, and socializing online, necessity drove many aspects of healthcare to being delivered remotely too. So, with vaccines being rolled out around the world and us starting to think about post-COVID health care, where does digital health go now? We spoke to two of BIOTRONIK’s most experienced digital health experts: Ken Nelson, Head of Digital Health, Diagnostics & Monitoring at BIOTRONIK US, and Dr. Naveed Khan, Director for Business and Commercial Development in Digital Health who works for BIOTRONIK’s global headquarters but is currently based in Australia. We asked them about how the pandemic has accelerated digital health, what role wearables might have in diagnosis, and what’s next for long-term arrhythmia monitoring.
COVID-19 has accelerated digital innovation around the world, including digital health and telemedicine. What do you think the longer-term impacts are going to be post-pandemic?
Ken Nelson: In the digital health world, there’s been a ton of innovation going on, particularly since 2010, and that has really ramped up in the past 5 years. New products have been getting approved around the world for years, whether by the FDA, CE Mark, or elsewhere. But reimbursement was not necessarily moving at the same pace and adoption of the technology was also not moving at the same pace as approvals. COVID has really forced us to become more aware of digital health solutions and adopt these technologies, including telehealth and remote patient monitoring. That’s a very good thing for patients and health systems. Overall, it really helps workflow efficiency, and improves disparities by helping to provide care to people who wouldn’t normally be able to access it. There will probably be a return to some semblance of the past after the pandemic ends, but I think a lot of this innovation is here to stay and will keep evolving.
Naveed Khan: I agree, a lot of that change in driving innovation in digital health solutions is probably permanent — especially if the virus becomes endemic and never goes away completely. It’s a different state of “normal” that will continue to drive ongoing digitalization. As an example, while we’ve had telehealth for a long time in Australia, obtaining reimbursement had been difficult for about ten years. COVID-19 quickly made that a necessity. Now both doctors and patients say it’s convenient and leaves them no worse off.
A lot of the [recent] change driving innovation in digital health solutions is probably permanent — especially if the virus becomes endemic and never goes away completely. It’s a different state of “normal” that will continue to drive ongoing digitalization.
Do you think the pandemic made patients and physicians more open to these technologies?
Nelson: I think you may have had some people who were a bit intimidated by telehealth at first or didn’t fully understand all the benefits. Then suddenly, we were in a situation where it’s indispensable in caring for patients. The industry already had many digital health solutions that were ready immediately. With COVID, the demand for telehealth and remote patient monitoring solutions exploded and the current digital health revolution emerged. Patients, physicians and hospital staff have gotten more comfortable using digital health technology, and now the digital health revolution is gaining speed. We did see some concerns from physicians and clinical staff that older patients wouldn’t be able to get their head around some of these technologies. But during this pandemic, we’ve seen that patients changed their behavior and adapted.
There will absolutely be long-lasting benefits after the pandemic as well. For example, patients can remain at home and save the time and transportation costs that can come up when visiting a physician. That’s particularly helpful for certain patients who might be on low incomes, live far away from their clinics, or both. Reimbursement has also helped make remote monitoring and other digital technologies more palpable for patients and clinics. It’s amazing to see how quickly the transformation and adoption of digital health solutions has taken place over the past 18 months or so.
Khan: More physicians are definitely appreciating the benefits of safe, remote follow-up with their patients and a lot of previous skepticism has disappeared. In Australia alone, we went from about five percent remote monitoring use to more than thirty percent in a very short space of time. Now that the advantages of digital health are clearer, it’s going to be harder to go back.
There is also another side to digital health evolution. There’s a lot of information and data that comes through remote monitoring that physicians need to review. How to optimize that process to make the review as easy as possible is one of the most pressing questions in digital health. The way physicians are trained, and the way practices are set up now, is not always in line with what it takes to run a successful remote clinic. I think we will see that the pandemic has accelerated the shift in the way physicians are setting up their practices to incorporate greater digitalisation and technology.
Patients seem to really like it though and, as one example of what Ken said, a lot of our patients in Australia live in very remote areas. It’s a large country with not a lot of people and some patients could be a long way from a clinic. If they don’t have to come in, and their follow-up can be done safely remotely, they’re really happy. What they want to know is that someone is continuing to look out for them.
With COVID, the demand for telehealth and remote patient monitoring solutions exploded and the current digital health revolution emerged. Patients, physicians and hospital staff have gotten more comfortable using digital health technology, and now the digital health revolution is gaining speed.
At a time when more people are using wearables and more researchers are studying their potential benefits, what is the role of high-quality, diagnostic and monitoring tools?
Nelson: Ultimately, we have to remember that there’s a difference between consumer grade and clinical grade products in terms of diagnostic accuracy. Consumer grade products like the health tracker on a smartwatch, is not going to have the same diagnostic accuracy for things like atrial fibrillation that a clinical grade monitor will have. But that doesn’t mean they can’t help in certain cases. In most cases, physicians are not going to make significant treatment decisions off of a 30 second rhythm strip from a smart watch. Consumer grade wearables simply can’t provide the necessary data quality for that. For example, if looking at atrial fibrillation, you don’t get AF Burden, you aren’t able to see onset or offset, and there are typically a significant rate of false positives with smartwatches. So they help as a screening device, but typically those patients will be prescribed a longer-term extended cardiac monitor, most likely a patch or, in some cases, depending on the indication, insertable cardiac monitors (ICMs) may be used. An additional downside to consider is that there’s enough false positive readings from consumer wearables that patients may end up worrying about a condition they don’t actually have. There’s also the risk physicians could get inundated with data that may not actually be helpful for diagnosing their patients. That’s why it’s so important for physicians to have proper guidance from heart rhythm societies around the world when it comes to important alerts from wearables or other consumer grade devices they should be investigating.
Khan: As Ken outlined, unfortunately a lot of the data coming from wearables now is noise. Patients are coming to their doctors with concerns, but the readings are simply not high-quality enough a lot of the time for physicians to act on. But the technology around this is getting better all the time, bringing with it the challenges of how practices can set themselves up to deal with that data review burden. Many practices aren’t set up for that yet and that’s where the industry can help with services that help manage all the data.
What do you think is next for clinical grade diagnostic and monitoring tools?
Nelson: I like to think we’re on the brink of another disruptive wave in the injectable market, and a major evolution in that technology — from an implantable loop recorder to an insertable cardiac monitor (ICM), to an injectable vital signs monitor. But there’s also a lot to be said for making more use of existing technology. We have estimates that only about a third of cryptogenic stroke patients are being monitored with an ICM. That leaves a lot of patients who might benefit from early detection of any atrial fibrillation. Depending on the patient, there’s also a case to be made for using an ICM to monitor patients who’ve undergone ablation, to see if atrial arrhythmias come back. BIOTRONIK’s BIOMONITOR IIIm has got great sensing and data quality, so over the next few years I think we’re going to see a shift to helping physicians analyze that data.
Khan: Most physicians are simply burdened with too much data to review which is usually out of clinical context — even when it comes to clinical-grade products before we consider wearables. So there’s always going to be a need to refine the underlying monitoring technology to make readings more precise, more specific, and better integrated into clinical workflow. We’re not going to get there overnight. But as we’ve been suggesting, the next frontier in digital health in this regard is pioneering services, fully or partially automated by Artificial Intelligence, that can help physicians manage workflows. That process must be based on patient indications at scale to a very high diagnostic accuracy. That’s already happening with diagnostics and arrhythmia monitoring in particular, and probably will expand to other disease states.
For related reading on digital health, check out the following articles on Remote Monitoring in Cardiology and Remotely Interpreting Device Parameters in HF Patients.