As the NHS faces a funding gap of £6 bn a year by 2015, E&T looks at the new technologies for better and less costly medical treatment of the UK's increasingly infirm and ageing population.
If we're honest, going to the doctor is up there with having teeth filled, completing our tax return, and other tasks that we know we must do, but would rather not. So it will probably be a relief to learn that emerging technologies could spell an end to at least some hospital and GP appointments, of which there are about 300 million in the UK each year (and 40 per cent of those, according to some sources, are unnecessary) while at the same time potentially cutting waiting lists and saving healthcare services money.
One evolving area is software that can carry out online patient interviewing prior to a visit to the GP. 'Computer-patient interviewing will develop over the next few years, and should make consultations more efficient,' says Ray Jones, Professor of Health Informatics at Plymouth University. 'If the interview makes it clear what is needed, the GP might not need to see the patient at all, or might be able to carry out the consultation via telephone or Skype. Also a lot of research shows patients are happier revealing embarrassing things to a computer than to their GP.'
Jones also sees the Internet being used more for both self-care (see 'DIY Healthcare' boxout, p25) and for remote group consultations, as in current US projects where clinicians run websites for groups of diabetics. 'Where you get clinicians involved, you could probably see a reduction in the number of face-to-face consultations, which in remote areas would have major implications for global warming by saving a lot of travel,' he says.
No therapist required
New computer-based solutions are also being explored for mental health problems, including anxiety and depression, which when combined form the most common mental disorder in Britain affecting almost 9 per cent of the population. 'The size of the problem of depression and anxiety is far greater than could be effectively treated with therapists,' says psychologist Dr David Purves, who has designed the 'Blues Begone' computer software package to help address this issue.
The program is based on Cognitive Behavioural Therapy (CBT), a proven method of helping people stop underestimating their strengths and overestimating threats. Unlike the previous generation of software used to deliver CBT, Blues Begone - which has been adopted by some UK local area health authorities - assesses the user via a questionnaire, then tailors the self-help exercises to fit by drawing on a database of 306 different program elements. A talking computer animation of Purves helps guide the user through the tasks selected by the program, while further animated characters describe their problems in case studies. Throughout the treatment, telephone contact by mental health workers helps keep people engaged with the program, which constantly monitors progress via built-in evaluation tests.
'In truth, all psychological treatment is self-help. So you have to empower the client to get the best outcome, and we need electronic systems that people can access and so help themselves,' says Purves, adding that in a recent study Blues Begone cured 60 per cent of patients with depression, and 50 per cent of anxiety patients. 'The World Health Organisation say that by 2020 depression will be the second largest burden of disease in the world. This [sort of technology] is something you can just scale up and deliver when people want it.'
Another way to reduce the need for medical assistance is to prevent avoidable accidents, such as falls, from happening.
Falls have a tremendous impact on the UK healthcare system, as 30 per cent of the over-65s have a fall each year, costing the NHS over £1bn - and, more importantly, lives.
'Half a million elderly are at risk of falling, and the majority of falls are due to an abnormal gait,' says Dr Diana Hodgins from European Technology for Business Ltd, designer of the Pegasus gait analysis device featured in 'A Question of Balance' (E&T Issue 17, 2009).
This small, strap-on device sends data from inertial measuring units to an ordinary PC or laptop and enables a gait analysis to be performed in under 10 minutes at a GP's surgery. 'Our goal is to quantify their gait (by measuring joint angle, stride duration and variability and phasing between the limbs) so they can be given an exercise regime to take them off the 'at risk' register. Everybody has got to look more at how to save money in the NHS, and the best way is early and correct diagnosis,' continues Hodgins.
Monitoring technologies can also help with rehabilitation. The main aims of Activ4Life's Pro V3.8 orthopaedic activity monitoring system, for example, are quicker hospital discharges, fewer post-operative visits to clinicians and an early detection of complications following hip and knee replacements.
The system consists of a wristwatch-sized monitor, attached with double-sided medical sticky tabs to the users' waist, and a docking station that receives encrypted data from the monitor's 2D accelerometers. Each night, the monitor is recharged in the dock, while the encrypted acceleration patterns that reveal if a user has been running, walking, shuffling or taking the stairs are sent to a secure server via the mobile phone network, along with the patient's report on how much pain they have been in.
By comparing the new data with a profile in the database (built up from results of ongoing trials) that matches the age, gender, BMI and post-operative state of the patient, a prediction is made of either degeneration of their condition or improvement. Exercise regimes are then suggested to optimise recovery, and try to stop people doing too much too soon and undoing their operation, or worse still not moving at all.
'The device shows patients what their daily activity has been and tells them what their clinician has indicated they should do,' says Dr Ian Revie who designed the system. 'Self-management encourages the patient to be less poorly, and we've shown in our trials that the clinical outcome for patients is 10-12 per cent better, if they are monitored.' In addition, Revie's estimates suggest standard use of the monitor would save at least 20 per cent of the current cost of treating each patient. 'The more treatments can be done in a remote fashion that we don't really need to see a doctor for, the more clinicians can focus on complex diseases,' says Revie.
Vital signs, such as blood pressure and pulse, can also be remotely monitored, and could play a role in managing patients with long-term disease.
The Mayo Clinic in the US (in collaboration with GE Healthcare and Intel) is half way through a year-long study to evaluate the effectiveness of in-home monitoring technology - which includes videoconferencing capability - in reducing hospital visits for patients with chronic health conditions. The hope is that detecting deterioration in a patients' condition at an early stage will enable prompt treatment that reduces the need for hospitalisation. An existing teleheaith service in the USA has alreday reduced hospital admissions by 20 per cent.
Videoconferencing has been used as part of e-health for years in countries such as Norway to provide consultations with dermatology specialists, located many miles away. It can also allow staff from different hospitals to have 'virtual meetings and so save on travel time and costs. The South West Wales Cancer Network showed during evaluation of their videoconferencing use that one site saved £5,100 in travelling expenses in just a month.
In pathology, not only is technology enabling access to specialists, it is also helping address a deficit of qualified staff. 'There is a severe shortage of pathologists in most parts of the world, including Japan, Canada, Australia, New Zealand and the UK,' explains Dr Jared N. Schwartz MD, former president of the College of American Pathologists and chief medical officer of digital pathology systems suppliers Aperio Technologies. 'So these countries are increasingly adopting a new technology, called 'whole slide scanning' where you scan the tissue sample on a slide and end up with an identical digital microscopic image of what you would have seen,had you been looking through the microscope.'
This scan does not suffer distortion during transmission, so can be sent to another location either via a secured network or over the Internet as long as patient identity is protected. This not only helps hospitals with no pathology staff on site, but provides access to pathologists specialising in particular areas, such as neuro-pathology when a second opinion is required, without lengthy delays and potential risk of loss or damage when mailing samples. In the future, digitising slides could reduce the need for storing the original samples for years, which Schwartz says 'would save significant space and money'.
Digitising the slides also enables computer-assisted diagnostic tools to be used. In general, pathologists are looking for a particular pattern or cell type within a tissue sample. Finding these specific cells involves looking through a microscope at hundreds of them, and the results are bound to be subjective. 'Five pathologists might give three different opinions, but a computer-assisted algorithm that counts thousands of cells may give the pathologist a statistically more standardised result,' says Schwartz. 'One of the hopes is that by using computer software that will improve over time, there will be increased standardisation of diagnoses, and we can be confident that our interpretation is more accurate.'
Despite predicting a range of new computer applications to help pathologists diagnose and forecast the progress of diseases, human analysis will not be eliminated in the foreseeable future, says Schwartz. 'I am optimistic that we will continue to have extraordinarily well-trained physicians to make sure the technology makes sense. No technology is foolproof, and when you're talking about people's health and lives, you are still going to have to have somebody to make sure all the results fit into what you're seeing from the patient.'
Ease of access
Some developments in e-health are just a matter of adapting existing technologies for use in a healthcare setting. In Australia, for example, the government has announced the introduction of personally controlled electronic health records and is working towards electronic prescribing and dispensing of medicines, which should increase the time healthcare professionals can spend with patients.
'When you're looking at what technology we should be encouraging, you're saying: what do the majority of patients want that can enhance what we know and delivers the best quality of healthcare for the best cost?' says general practitioner Grant Ingrams, chair of the British Medical Association's GP IT committee. This doesn't have to be high tech. 'I think telephone consultations and email will become more common, but in addition to normal consultations - which have gone up by a third over the last 10 years and continue to rise. So we've got to look at how to be more efficient, and these things might help,' explains Ingrams.
He finds email particularly useful, if he needs patients to record regular measurements of things, like blood sugar levels, then send them to him for review. 'It's a fantastic way of doing it because it means they haven't got to wait for me to have an appointment free to talk to them,' says Ingrams.
One feature of all these advances is the human intervention required, so the idea of being cured by a 'virtual doctor' is likely to remain science-fiction for some time. 'I still need to read and interpret any information, and the majority of patients prefer to see a doctor above any other type of service,' concludes Ingrams.