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March 2, 2021
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“The technology toothpaste is out of the tube. It’s not going back in!” – John Nosta

Technology lives in a pulse of “wonder and fear,” claims John Nosta, the founder of NostaLab, innovation theorist, and member of the Digital Health Roster of Experts at the World Health Organization. In an interview with Artur Olesch for The Sidebar, he explains the transformative power of technology in healthcare. COVID-19 has significantly accelerated the adoption of digital technologies in healthcare. Will this acceleration continue in the coming years?

Telemedicine took off in 2020, particularly in the early phase of the pandemic. But what I’m seeing at the moment is a precipitative drop. I don’t think it’s fair to say that digital health has come of age. When I looked at some of the data, I found that telemedicine visits have gone down significantly and, in certain instances, are almost right back to the baseline or pre-COVID-19 level. This is concerning.

We need to take a look at the dynamic of digital health adoption. I do not believe that COVID-19 is the game-changer in digital health. I see that people have adopted the technology out of necessity, urgency, and fear but have not incorporated it into their lives as a mainstream practice. There’s a duality here: We do certain things because “we have to,” not because “we want to.” But the transition has to be centered around the area of “wanting to.”

I believe that COVID-19 has put digital health on people’s radar screens: clinicians, patients, payers, caregivers. Still, there remains a lot of work to be done to integrate health technology into our lives and in clinical practice.

If COVID-19 is not the game-changer for digitalization in healthcare, what could it be?

When we look at the factors required to drive the adoption of digital health, there are a variety of perspectives. It’s not a simple idea or magic bullet. Above all, we have to look at the various stakeholders. There is a tremendous interplay between the patient and the clinician. And they both act as a sort of validator of each other.

Firstly, we must have technology that patients find friendly, appropriate, and usable. Similarly, physicians should find the technology usable and relevant. It must fit into their clinical dynamic and methodology of practice. This is one of the most critical areas that need to be addressed. Secondly, clinical validation also matters. We need to start looking at technology and its outcomes from a more functional perspective. Does the technology provide any tangible benefit? Or is it just hype?

We live with two poles: the patient and the provider. To a certain degree, there’s a little bit of “push and to pull.” We can “push” an idea towards a patient, but the physicians have to understand it and believe that it fits into their practice, thereby allowing for a continuum of care. For example, the ability to measure steps is a wonderful concept. For patients, it’s a metric of wellness. However, I’m not sure if clinicians understand that it could have some functional significance other than an activity of daily life. We need to be able to assimilate data in technology into an established clinical workflow. That’s very important because clinicians like things that are the same but better versus a complete revolution in care. We have to remember that physicians tend to be conservative because they are dealing with human lives. Errors can have a significant impact on patients’ lives.

You mentioned that we are living with the “patient-provider” poles. What about the regulatory framework and healthcare politics?

Of course, it’s an oversimplified concept. But certainly, at least in the United States, regulatory conditions and reimbursement are often essential to driving adoption. But if the patient doesn’t want to use the technology and the physician doesn’t understand how it fits into the clinical workflow, or if there is no clinical validation and regulatory approval, reimbursement does not guarantee adoption.

At present, we live in a triple inflection point, a unique time in human history. First and foremost, we already have the technology – we can make ECG measurements in the home, communicate remotely, control health with smartwatches. Ten years ago, it would have been a very different story. Secondly, we see governments, regulatory bodies, and payers accepting that this technology is a way forward. I’m not going to claim that digital technology is being embraced, but at least digital technology is being more readily accepted.

The third inflection point is that implementing technology is the right thing to do, a moral imperative. That is, pushing patients and clinicians towards the adoption of digital tools is the right thing to do. After all, lives are at stake. These three factors are all coming together and becoming a fundamental driver towards putting digital health into the spotlight. Nonetheless, this doesn’t guarantee success.

Many people are now embracing digital health. However, let us suppose that the technology doesn’t work well or that the user experience is not appropriate. In that case, clinicians don’t know how to integrate the technology into their workflow. Not only will it be rejected, but it will fail with possibly tragic consequences. Moreover, just because people want the technology or like it doesn’t guarantee success. In fact, this phenomenon exposes the vulnerability of health technology in the marketplace.

Digital health solutions are improving very rapidly, thereby offering an increasingly enhanced user experience. Is it possible that soon, telemedicine will be better than an in-office visit? What will be the tipping point for such a change?

That is such a fundamental concept: “Can we make some aspect of technology better than a visit to a doctor?” There are many things that come to mind: telemedicine, the computer.

I believe that the opportunity is there and that telemedicine visits can become better than office visits. But “better” is a very subjective word. For example, if clinical efficacy decreases by 5 percent, but convenience increases by 100 percent, then is telecare better than an office visit? The question is: How willing are we to compromise efficacy for convenience? Concerning the present challenges, there are vaccines with a 95% or 99% effectiveness. But they all passed a threshold of utility. This is something that we need to consider in digital health: The balance between clinical acceptability, convenience, and patient engagement. In addition to the type of use and clinical situation, we can see that efficacy and convenience aren’t absolutes—but rather conditions that vary. Point of care ultrasounds at the scene of a car accident may not have the very best resolution and image quality—but it’s an idea suitable for the situation.

But I also think that by leveraging our existing technologies today, we may make the clinical exam better than the office visit. We can transform punctuated office visits into a level of continuous care. One of the biggest problems I see today is that we’ve taken the office visit and replaced it with the Zoom call. Let’s take a look back at things like the early evolution of the world wide web. When we first created websites, we made them very generic. But later, we found that user experience is vital. If we optimize the experience provided by the website, it becomes more engaging, robust, and also more effective.

What we need to do is to develop something like a UX for telemedicine where we optimize engagement and not only with respect to a clinician talking to a patient using a model of 1 to 1 communication. The question is, how can we incorporate, in real-time, certain digital devices? How to integrate them into the telemedicine visit in order to optimize care? Moreover, telemedicine visits don’t have to start and stop. Why can’t a telemedicine visit be a continuous ongoing dynamic that can be occasionally punctuated by the traditional, face-to-face meeting with the clinician?

That’s an exciting perspective. However, some say that as humans, we are used to human-human relations in healthcare.

Remember that the continuous improvement of the candle never gave us the light bulb. Innovation and technology are advances that live in a pulse of “wonder and fear.”

Suppose we go back to our first technology, which I believe is fire. Fire changed the world. It allowed us to move, stay awake at night, keep warm, cook, and eat more protein-based food, which in turn led to the development of the human brain. And yet, today, fire is one the single largest causes of property and personal destruction. A fire can light the darkness, but it can also be used as a weapon or even kill us. And that duality seems to exist in the context of innovation in healthcare. Interestingly, the bigger the innovation, such as AI, the more powerful and significant is that sense of wonder and fear.

From one perspective, telemedicine visits are seen as beneficial. But on the other hand, it’s not the traditional way doctors, and patients tend to interact. A classic example of the “wonder and fear” dynamic is the airplane. When flying first became possible, planes were terrifying – it was an act of heroism to fly in an airplane at the beginning of the last century. But today, aircraft have become the safest form of transportation. It took 67 years for the airline industry to carry 50 million passengers.

In a world of exponential change, that dynamic of adoption accelerates tenfold. A good example is a driverless car. Whether you admit to it or not, most people are a little bit nervous about getting into an autonomous vehicle and driving along a highway. It’s scary. But also, it’s one of the coolest things you could do. I can imagine that the traction, or general social acceptance – the journey from fear to wonder, which is defined by a sense of safety – will probably take about ten years. It’s the same dynamic as with the airplane, but it’s going to happen ten times faster because of the nature of exponential change. Telemedicine will move along that path. However, in this case, the human factor plays a significant role. So when you compare conventional care with digital care, it’s violating the sacred act of the human relationship with the physician. And that’s part of the problem.

At this point, a question to consider would be, what will be the driver for technology in health care?

Let’s return to the example of the driverless car. I believe that the adoption of the autonomous car in ten years will be driven neither by convenience nor by joy or user experience. It will be accelerated by insurance companies. Why? Because humans are just too dangerous. In the United States alone, 45 000 people die every year from car accidents. Seeing how the power of AI in the autonomous car decreases the number of accidents, AI becomes imperative. That dynamic is a little easier to understand in the context of driverless cars because it’s such a game-changing perspective.

By analogy, as we see the power of data in improving outcomes and reducing morbidity, AI will be mandated by those who hold the strings – I mean regulatory bodies, insurance companies, payers, patients, and clinicians who recognize that this is a way forward.

What fascinates you most concerning the new technologies in healthcare?

I believe that fundamental change is at hand and will be defined by the wonder and fear dynamic. In a traditional clinical construct, when the doctor enters the exam room, he or she is the smartest person in the room. But now, technology, particularly analytics and AI, can become that smartest “person” in the room. This will allow clinicians to address the cognitive limitations which may affect their ability to provide optimal care. Big Data and analytics will change this dynamic and free up clinicians to provide access to more rich and insightful information. This is really going to change the game.

But what will happen when clinicians gain more time for their patients. Is my mother’s cardiologist willing to spend 15 minutes chatting with her about her physical condition? I’m not so sure about that. There are two tragedies in life. One is not getting what you want, and the other is getting it.

If technologies are to make medicine better, what should be done to make this dream come true in the next 5 – 10 years?

We have to recognize that the technology toothpaste is out of the tube. It’s not going back in. I think that some clinicians are a little bit resistant to change. This is due to human nature, but also due to the health care financing system. Physicians are paid for their services. Once we start changing that dynamic, it’s going to impact the financial aspect of care. And that’s a real perspective. Innovation is influenced by a variety of issues: accessibility, the ability of clinicians and patients to use and understand it, and also the existing regulatory and financial constraints.

The diffusion of innovation is a process. The idea of just building a great solution that will simply be accepted and adopted is false. Big companies like Apple and Google have failed to introduce many new products. Google’s phone failed. You have to follow the process. You must position a product appropriately, have the right data, and go to the right audience. Often, many digital health innovators just focus on the solution itself. Once they try to bring it to the market, they just think that everyone will love it. This perception is wrong. We’ve also witnessed this pattern for digital innovations validated through clinical trials. Their uptake in the healthcare market often takes time and the implementation of a process.

John Nosta is a leading voice in the convergence of technology and health, defined as “most admired” to “top disruptor” in digital health, life sciences, and the pharmaceutical industry. He is a member of the Google Health Advisory Board and a World Health Organization technology expert. Further, John is a frequent contributor to Fortune, Forbes, Psychology Today, and Bloomberg. He is the founder of NOSTALAB—a digital health think tank focused on guiding companies, NGOs, and governments through the dynamics of exponential change in technology marketplaces.

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About the author

Artur Olesch

Artur Olesch is a Berlin-based freelance journalist and correspondent for digital health-related topics.

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