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Is Medicine Ready for the Digital Revolution?

With the industrial revolution of the 20th century (1), the world began a new and successful chapter in the war against infectious or "communicable" diseases. (2) Annual mortality from these diseases has plummeted by 90% to record lows, except in the poorest of countries. (3) What remains as the leading causes of death and disability worldwide are the so-called non-communicable diseases (4) with vascular disease of the heart and brain, and cancer accounting for the vast majority. (5) Attention has shifted to efforts to control the epidemic of "non-communicable" diseases so patients can live healthy lives and age in place, free of physical or mental impairments. (6)

Today, with lifespan increased and communicable diseases largely tamed (7), attention has shifted to controlling the emerging epidemic of non-communicable diseases. The American Heart Association has defined an equation to determine optimal cardiovascular (CV) health (8) and has quantified the gap in CV health in today's US population, as well as the benefits of shifting individuals toward more optimal scores. (9) Epidemiological studies have shown that optimal CV health accrues many benefits beyond prevention of coronary and cerebrovascular events, with impressive reductions in prevalence of cancer, chronic kidney disease, pneumonia, venous thromboembolism, pulmonary diseases, dementia and fractures. (10) While our previous clinic-pathologic taxonomy of dementia segregated "vascular dementia" from Alzheimer's disease (11), recent data suggest that up to 50% of Alzheimer's disease may be due to lifestyle and CV risk factors, and that cerebrovascular events may trigger the onset or worsening of Alzheimer's pathology. (12) Data from Framingham Offspring participants confirms that ideal CV health is associated with reduced risk of stroke, vascular dementia, brain atrophy and cognitive decline. (13)

It is also acknowledged that poor control of vascular risk factors due to medication non-adherence and lifestyle choices that contribute to obesity, unhealthy diet, inactivity, smoking and excessive drug or alcohol use, accounts for much of the disease burden that subsequendy occurs. (14) Of profound interest to this conversation is compelling data from the last decade that many of the factors that are driving the rise of non-communicable diseases are themselves "communicable". This theory of "social contagion" gained traction with the observations by Christakis and others of the spread of obesity, smoking and other deleterious behaviors across social networks of individuals while completely sparing their geographic neighbors. (15) In an ethically questionable social experiment among ~700,000 unconsented users, Facebook demonstrated that simple manipulation of the emotional content of a user's newsfeed could predictably amplify or suppress positive or negative emotions by the user. (16) Fortunately, there is emerging evidence that healthy behaviors can also be transmitted through social networks. (17) Analysis of activity monitoring devices in a worldwide social network of athletes demonstrated the positive influence that an increase in physical activity by some members can have on other members of a social cluster, inspiring them to increase their pace or distance. (18) We know understand that unhealthy behaviors can spread like viruses, passing from person-to-person who are in intimate "social" but not physical "contact" with each other to ravage whole communities. Perhaps because they exert their influences slowly, lying apparently dormant for years while they inexorably erode the health of their hosts, the contagious nature of their spread has eluded us. Just as a prior generation of public health experts used the tools at hand to interrupt this cycle of spread of pathogens through hand washing, sanitation and vaccination, so to must we retool to fight this new epidemic of "communicable" behaviors. This battle won't be fought or won in cell culture systems, but rather in the dwellings, restaurants, gyms, parks, schools, workplaces and social networks of our patients. With the ubiquitous availability of smartphones and wearable devices, new opportunities exist to measure physiology and behavior in situ (i.e., digital phenotyping) and to engage with our patients to intervene before disease events occur using telehealth whenever and wherever it is most appropriate.

Clayton Christensen (19) has eloquently described the force of disruptive innovation in our current economy, upending established companies left and right. (20) These disruptions occur as the products and services offered by companies increase in features and prices that ultimately exceed the needs of consumers. As alternative offerings reach the level of "good enough" at more affordable prices, higher priced companies rapidly become extinct. When whole industries collapse, the effects are not dissimilar to the mass extinction events observed in biological systems. These events occur when major changes in populations or environments apply rapid evolutionary pressure that leads to the collapse of a prior dominant species and the emergence of a new dominant species. It is challenging for dominant companies or organisms that are in the midst of such a mass extinction event to recognize or adapt to what is happening until it is too late, since they evolved to their dominant position precisely by being maximally adapted to their environment, that is by following the traditional approaches that worked so well in the past. Every day it seems we read about new companies entering the healthcare space, from digital health startups, to dominant information services companies partnering with service delivery organizations such as pharmacies to create new models of care. It is reasonable to wonder if the medical profession is in the midst of a climate of disruptive digital and market innovation that will render our traditional models of hospital- and provider-centric care delivery for the prevention and treatment of vascular disease irrelevant or extinct.

Telehealth and digital health refer to the use of electronic services to support a broad range of remote services, such as patient care, education, and monitoring. To achieve its full potential, I have argued previously that telehealth must be integrated into our traditional practices both in ambulatory and hospital-based settings. It must also address all six domains of care quality defined by the Institute of Medicine by providing care that is safe, effective, patient-centered, timely, efficient, and equitable. Telehealth and digital health are disruptive technologies that threaten traditional fee for service health care revenue and delivery models but also have the potential and promise to transform the industry by reducing costs, increasing quality and improving patient experience and satisfaction. There are seven strategies critical to successful telehealth implementation and they include setting appropriate patient and provider expectations, untethering telehealth from traditional revenue expectations, deconstructing the traditional health care encounter and reassembling it for a digital environment, being open to the discovery of new ideas, being mindful of the importance of a safe "space" within which to conduct digital health encounters, redesigning the encounters to improve the economic value in health care, and being bold and visionary in this transformation. (21) Important cost savings may accrue through the use of digital health by reducing transportation costs with its associated carbon emissions, especially for rural or low-income populations. Telehealth, especially home-based deliver)', may be an affordable alternative to meet the healthcare needs of vulnerable populations who have multiple comorbid conditions and/or limited mobility and who require frequent healthcare services, and may facilitate patient engagement in shared decision-making.

Patients are increasingly connected to each other, to devices and to the world, through vast social networks and information technology that is expanding and evolving exponentially. Technical challenges that seemed decades beyond reach are now solved in years, and machine learning strategies are transforming data analytics and mathematical prediction algorithms. Society is also changing rapidly, and our strategies to preserve brain health and heart health must reflect and leverage the tremendous diversity of our patients and help to guide our approach. We must embrace this rapid force of change and harness it for the good of our patients and society. We should evaluate the critical success factors in the fight against infectious diseases and apply those principles in our current efforts against "non-communicable" diseases. We must engage deeply with our patients, in their communities (both geographic and online) and in their lives, if we hope to "immunize" them with interventions that promote healthy behaviors. Our traditional methods of behavioral intervention are costly, ineffective and behind the times. We must embrace new technologies and be on the forefront rather than the trailing end of defining how they will best serve the needs of our patients. What matters most to patients is the ability to live healthy lives and age gracefully, free of physical or cognitive disability. They have placed their trust in us, and we owe it to them and ourselves, to do our utmost to meet that challenge.

By Lee H. Schwamm, M.D., Dr. Schwamm is the Executive Vice Chair of Neurology and the Director for the Center for TeleHealth and Comprehensive Stroke Center at Massachusetts General Hospital, and Professor of Neurology at Harvard Medical School. Dr. Schwamm may be reached at Lschwamm@mgh.harvard.edu

(1) See generally A Brief History of Public Health: Industrial Revolution, BOSTON UNIV. (2015), available at http://sphweb.bumc.bu.edu/otlt/MPHModules/PH/PublicHealthHistory/publichealthhistory4.html (last visited Feb. 28, 2019).

(2) Tynan DeBold and Dov Friedman, Battling Infectious Diseases in the 20th Century: The Impact of Vaccines, The Wall Street Journal (Feb. 11, 2015, 3:45 PM), http://graphics.wsj.com/infectious-diseases-and-vaccines/. See also, Robyn Correli, The Differences Between Communicable and Infectious Diseases, Very Well Health (May 21, 2018) https://www.verywellhealth.com/ the-difference-between-communicable-and-infectious-diseases-4151985. A communicable disease is contagious, and the effect is external, which can lead to small, isolated outbreaks or full-scale outbreaks. Id. An infectious disease can cause an infection, but the affect is internal, pathogens come inside your body and spread throughout. Id. While all communicable diseases are infectious, not all infections are communicable. Id.

(3) Achievements in Public Heath, 1900--1999: Control of Infectious Diseases, 48 MORBIDITY AND MORTALITY WKLY. REP. 29 (1999). Poorer countries have a more difficult time implementing the strategies developed to combat communicable diseases due to poor housing conditions, inadequate public water supply, and an absence of waste-disposal systems. Id.

(4) Noncommunicable Diseases, WORLD HEALTH ORG., (June 1, 2018), https://www.who.int/newsroom/ fact-sheets/detail/noncommunicable-diseases (last visited Feb. 21, 2019). These are chronic diseases such as cardiovascular disease, cancers, chronic respiratory diseases, and diabetes which are a result of a genetic, physiological, environmental and behavioral factors. Id.

(5) See World Health Organization, The Global Burden of Disease: 2004 Update, 1, 48 (2004), http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf?ua= 1. The risks of noncommunicable diseases generally increase with age. Id. High-income countries have been dominated by the risk of noncommunicable diseases because these countries have large aging populations. Id. See also Craig W. Moscetti & Allyn L. Taylor, Take Me to Your liter. Politics, Power and Public-Private Partnerships with the Sugar-Sweetened Beverage Industry in the Post-2015 Development Agenda, 24 PAC. RIM L. & POL'Y. 635, 635 (2015). Non-communicable diseases are a global health problem and a critical threat to development in the twenty-first century. Id. Non-communicable diseases, which include heart disease, diabetes, cancer, and chronic lung disease, as well as other risk factors, such as unhealthy diets, lack of physical activity, abuse of alcohol, and tobacco use have caused a large percentage of the world's deaths in recent years. Id. at 636. Additionally, these statistics are expected to grow over the coming decades and will represent 70 percent of global deaths by the year 2030. Id.

(6) See Cherian Varghese, Better Health and Well-Being for Billion More People: Integrating Non-communicable Diseases in Primary Care, The BMJ (Jan. 28, 2019). https://www.bmj.com/content/364/bmj.I327. Primary care is one of the best ways to detect and undertake the management of non-communicable diseases. Id. See also Roger S. Magnusson, Global Health Governance: Global Health Governance and the Challenge of Chronic, Non-Communicable Disease, 38 J.L. MED. & ETHICS 490, 495 (2010). "Until recently, non-communicable diseases were a neglected area of global health policy." Id. The emergence of new initiatives focuses efforts on prevention and treatment to fight against these diseases, which are dominating causes of death and disability in developed countries globally. Id. See also Bryan Thomas & Lawrence O. Gostin, Tackling the Global NCD Crisis: Innovations in Law and Governance, 41 J.L. MED. & ETHICS 16, 19 (2013). Governments at the national and state level will be the main actors in efforts to combat and control non-communicable diseases through the passage of laws and regulations. Id. See generally NCDnet, NCDnet- Global Noncommunicable Disease Network, WORLD HEALTH ORGANIZATION, https://www.who.int/ncdnet/en/ (working collaboratively to reduce risk of non-communicable diseases in low to middle-income countries).

(7) See Life Expectancy, WORLD HEALTH ORG., (2018), https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/ (last visited Feb. 17, 2019). The life expectancy in 2016 was averaged at 72 years old. Id. Life expectancy has increased 5.5 years from 2000 to 2016. Id. This reverses some of the decline in the 1990's from the AIDS epidemic. Id. Furthermore, the rate of HIV/AIDS and tuberculosis related deaths in the U.S. has declined, and globally the rate of HIV related deaths has decreased. See Christopher J. L. Murray, Deaths and Infections from HIV and Tuberculosis Decline Sharply In US, IHME (July 21, 2014), http://www.healthdata.org/news-release/deaths-and-infections-hiv-and-tuberculosis-decline -sharply-us. See also Christopher J. L. Murray, Global, Regional, and National Incidence and Mortality for HIV, Tuberculosis, and Malaria During 1990-2013: A Systematic Analysis for the Global Burden of Disease Study 2013, 384: 9947 THE LANCET 1005 (July 21, 2014), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202387/.

(8) See Eduardo Sanchez, Ideal Heart Health Over I jong Term Is the Best Medicine, AMERICAN HEART ASSOCIATION (May 15, 2018), https://healthmetrics.heart.org/ideal-heart-health-over-long-term-is-the-best-medicine/ (last visited Feb. 28, 2019). The metrics for analyzing heart health are "smoking status, eating patterns, physical activity levels, body mass index, blood pressure, cholesterol level, and glucose level" (referred to as the American Heart Association's "Life's Simple 7 metrics). Id. In sum, it is best to focus on heart health for the long term. Id. See also Lifestyle Changes for Heart Attack Prevention, AMERICAN HEART ASSOCIATION, https://www.heart.org/en/health-topics/heart-attack/life-after-a-heart-attack/ lifestyle-changes-for-heart-attack-prevention (last visited Feb. 18, 2019). The AHA has focused on high cholesterol being a "disaster waiting to happen." Id. The total cholesterol is determined by: High-Density Lipoprotein (HDL) (also known as "'good' cholesterol") + Low-Density Lipoprotein (LDL) (also known as "'bad' cholesterol" + 20% of an individual's triglyceride level equaling the total cholesterol score (HDL + LDL + 20% of triglyceride level = cholesterol score). Id.

(9) Garth Graham, Disparities in Cardiovascular Disease Risk in the United States, 11 CURRENT CARDIOLOGY REV. 238, 243 (2015). The need to close the gap between healthcare access and racial discrimination is necessary to increase the overall health for communities. Id.

(10) Oluseye Ogunmoroti, et al. Association Between life's Simple 7 and Noncardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis, 5 JAHA 10 (2016). Reducing the risk of cardiovascular disease through better control of risk factor associated with lower rates of other illnesses such as cancer and dementia. Id.

(11) See N.L. Graham et al., Distinctive Cognitive Profiles in Alzheimer's Disease and Subcortical Vascular Dementia 75 JNNP 61, 68-70 (2004) (comparing cognitive impairments in patients with vascular dementia versus Alzheimer's disease patients); Stella Karantzoulis & James e. Galvin, Distinguishing Alzheimer's Disease from Other Major Forms of Dementia, 11 EXPERT REV. NEUROTHERAPEUTICS 1579, 1582-84 (2011) (comparing Alzheimer's and vascular dementia). But see Perminder S. Sachdev et al., Vascular Dementia: Diagnosis, Management and Possible Prevention, 170 MED. J. AUSTL. 81, 83 (1999) (calling for further study of relationship between vascular dementia and Alzheimer's disease); William C. Groves et al., Vascular Dementia and Alzheimer's Disease: Is There a Difference? A Comparison of Symptoms by Disease Duration, 12 J. NEUROPSYCHIATRY AND Clinical NEUROSCIENCES 305, 311-13 (2000) (questioning whether vascular dementia and Alzheimer's disease are different entities).

(12) See Deborah E. Barnes & Kristine Yaffe, The Projected Effect of Risk Factor Reduction on Alzheimer's Disease Prevalence, 10 LANCET NEUROLOGY 819, 825 (2011) (finding up to half of risk of Alzheimer's Disease is attributable to modifiable risk factors). The seven potentially modifiable Alzheimer's risk factors are diabetes, midlife hypertension, mid-life obesity, smoking, depression, low educational attainment and physical inactivity. Id. See also Johannes Attems & Kurt A. Jellinger, The Overlap Between Voscular Disease and Alzheimer's Disease--Lessons From Pathology, 12 BMC MED. 206 (2014) (finding Alzheimer's and vascular or other pathological processes may influence progression, severity of cognitive decline).

(13) Matthew P. Pase et al., ASS'N OF IDEAL CARDIOVASCULAR HEALTH WITH VASCULAR BRAIN INJURY & INIDENT DEMENTIA 1201 (2016), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5006676/ (explaining reduced risks associated with ideal cardiovascular health).

(14) See David Lee, Ishak Mansi, Sujata Bhushan & Roy Parish, Non-Adherence in At-Risk Heart Failure Patients: Characteristics and Outcomes, 1 J. NATURE & SCI. 5 (2015). This study examined the effect of non-adherence among heart failure patients who were at increased risk for readmission. Id. The study showed that "non-adherence was a significant variable affecting heart failure readmissions." Id. at 4.

(15) Nicholas A. Christakis & James H. Fowler, The Spread of Obesity in a Large Social Network over 32 Years, 357 NEW ENG. J. MED. 370 (2007) (suggesting both good and bad lifestyle choices can be influenced by social relationships).

(16) Kramer AD, Guillory JE, & Hancock JT, Experimental Evidence of Massive-Scale Emotional Contagion Through Social Networks. 24 PROC. NAT'L ACAD. SCI. U.S.A. 8788 (2014). This experiment tested whether emotional content in a Facebook user's News Feed effected how that user posted. Id. The study found that when positive expressions were reduced users posted fewer positive posts and vice versa. Id.

(17) Albert Bandura, Health Promotion by Social Cognitive Means, 31 HEALTH, EDUC. & BEHAV. 143 (2004). "We can further amplify our impact on human health by making creative use of evolving interactive technologies that expand the scope and impact of health promotion efforts." Id. at 162.

(18) Sinan Aral & Christos Nicolaides, Exerdse Contagion In A Global Social Network, Nature Communications 8 NATURE COMM. ART. 14753 (2017), available at https://www.nature.com/articles/ncommsl4753 (last visited Feb. 21, 2019). Results from daily recorded exercise patterns showed that exercise behavior is socially contagious and that the level of its contagiousness varied based on relative activity levels and gender relationships between friends. Id. Less active runners influence more active runners, while the more active runners do not influence less active runners. Id. The activity behavior of men and women influences men, but only the activity behavior of women influences other women. Id.

(19) Clayton M. Cristensen, et al., Will Disruptive Innovations Cure Health Care?, 78 HARV. BUS REV. 102 (2000), available at https://hbr.org/2000/09/will-disruptive-innovations-cure-health-care (last visited Feb. 21, 2019). It is critical for the health care industry to prepare itself for disurtive innovation and competition from lower cost alternative care delivery methods. Id. By allowing new technologies and business models to influence the industry, the quality of health care will improve for everyone. Id.

(20) See id. (arguing disruptive innovations increase convenience, affordability of services, and quality of life). Disruptive innovation is a process where a smaller, less financially stable company is able to successfully challenge an established business by new innovations that offer services at a lower price with incrementally increasing quality. See also Clayton M. Christensen, What is Disruptive Innovation?, HARV. BUS. REV. 44-55, (Dec. 2015), https://hbr.org/2015/12/what-is-disruptive-innovation (last visited Feb. 28, 2019).

(21) See generally Lee H. Schwamm, Telehealth: Seven Strategies to Successfully Implement Disruptive Technology and Transform Health Care, 33 HEALTH AFFAIRS 200 (2014) (outlining the importance of seven key strategies in telehealth implementation).
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Author:Schwamm, Lee H.
Publication:Journal of Health & Biomedical Law
Date:Mar 22, 2019
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