COVID-19: side effects of healthcare’s digitalization in England – harnessing the positives and mitigating the negatives

In this original editorial piece, Simon Brassel, Kyann Zhang and Mireia Jofre-Bonet (all at The Office of Health Economics, London, UK) reflect on the potential positive and negative effects of digitalization – which has been accelerated by COVID-19 – on the future of healthcare in England.

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In 2019, the NHS specified increased digitalization of the healthcare system as part of its Long-Term Plan [1]. The recent outbreak of COVID-19 – and the subsequent measures implemented to curb its spread – has forced the acceleration of this process, with many of the rapidly implemented changes expected to have long-lasting effects.

The field of digital health technologies (DHTs) is highly complex and encompasses a wide range of measures including, for example, digital systems and services run in the background to allow digital health data to be processed and interlinked. These provide the functional foundations for other digital (health) products, such as those used by health care professionals (HCPs) to boost health service capacity during the outbreak [2]. As well as this, many DHTs are used by patients to improve management of care or for maintaining communication with their HCP. Such DHTs include (mobile) apps, online information services or software and digitally enabled devices.

In this piece, we reflect on the potential positive and negative effects of digitalization on the future of healthcare in England and provide a few suggestions on ways that could optimize their effects on health outcomes.


Potential benefits of digitalization include improved health access and outcomes through enhanced personalized care

DHTs have the potential to substantially lower the costs associated with searching, replication, transportation, tracking and verification of information [3]. Thus, digitally enabled care presents clear advantages compared with non-digital approaches for certain processes.

The NHS has been actively promoting digital-first primary care [4], which supports both patients – by allowing them to find information on symptoms as a first step – and general practitioners – by automating triage, facilitating appointment booking and communication and, thus, minimizing face-to-face consultations. The effect is already observable: data from the Royal College of Physicians [5] (London, UK) demonstrates that between mid-March and mid-April of 2020, 71% of routine consultations in general practices were delivered remotely, with only 26% taking place in person.

Another positive effect of digital health is the potential increased personalization of care. Recently, personalized feedback using internet counselling for the elderly [6] has been shown to modestly improve health outcomes. More complex digitally enabled products, such as closed-loop systems for Type 1 diabetes – which release insulin in response to detected changes in blood glucose levels of the user [7] – have enabled the highest level of personalized care, i.e. the tailoring of medical treatment based on individual patient characteristics. Such levels of personalization would be prohibitively costly if carried out through traditional channels and are only made possible through the lowered cost afforded through digitalization.


Potential negative effects mainly relate to greater uncertainty regarding health outcomes and the widening of inequality

Currently, there remains substantial uncertainty about the experience of virtual consultations and the long-term impacts on patient–physician relationships.

While digitalization allows more patients to access their HCPs, it is unclear whether the level of care provided is of equal quality compared with that of in-person consultations. One of the most criticized aspects of early virtual care trials has been its de-personalization of the patient–provider experience[8]. Recent evidence in the UK suggests video consultations are less information-rich compared with those carried out in person [9], despite the fact that patients generally liked the approach.

A more challenging problem, in the long run, may be the potential for existing digital inequalities to exacerbate health inequalities [10]. The ‘digital divide’ – a term for the gap between those who do and do not have access to computers and the internet and, further, between those who have the skills to be digitally engaged and those who do not – may exclude certain groups of individuals from access to virtual care.

Those who are unable to access or use DHTs may be limited in their access to certain healthcare services; eventually, this may lead to poorer health outcomes in already disadvantaged groups. For instance, in high-income countries such as the UK, the digital divide is characterized more by a lack of skills or usage related to modern technologies rather than by a lack of physical access [11]. In such cases, measures to extend physical digital access alone are unlikely to solve this problem.


Maximizing the benefits of digitalization will require active mitigation strategies

As it stands, digitalizing healthcare is unlikely to benefit every individual equally. This potentially undermines the 2012 Health and Social Care Act [12] – which obliges clinical commissioning groups and HCPs to reduce inequalities in their population – and the Equality Act of 2010 [13].

It should also be noted that in the case of a highly infectious disease such as COVID-19, there is a public health argument to be made in addition to the legislative and moral considerations for preventing health inequalities, as the disease cannot be controlled – much less eliminated – without it involving the whole population.    

However, increased digitalization may itself be the key in mitigating – to some degree – negative outcomes. Aforementioned lower costs associated with searching, tracking and verifying medical information could allow HCPs to more efficiently monitor health outcomes and, thus, potentially alert them to any adverse impacts both at the patient level – for example, poorer health outcomes – and on a wider societal level – such as increased disparities in health equalities.

Digital tools – such as dashboards that provide readily accessible visualization of equality indicators – for physicians and clinical commissioning groups could help identify and tackle inequalities within their populations more effectively and, hence, mitigate negative effects.

In the long run, balancing the positive and negative effects of digitalization will require a coherent strategy involving policymakers, technology developers, patients and HCPs. This will require the cooperation of sectors beyond healthcare, i.e. by increasing digital skills education to narrow the digital divide and improving the health literacy of the general population to make better use of medical information. Due to the range and variety of alternatives, more empirical research is needed to identify the most effective tools and strategies that will inform future policies.

While we acknowledge that this is a challenging task – made all the more so by COVID-19 – we emphasize the importance that research regarding the outcomes of digitalization keeps pace with the digitalization itself.


Disclosures:

Simon Brassel, Kyann Zhang and Mireia Jofre-Bonet are employees of The Office of Health Economics (London, UK), a registered charity and Independent Research Organisation which receives funding from a variety of private and public sector sources.
The opinions expressed in this feature are those of the interviewee/author and do not necessarily reflect the views of The Evidence Base® or Future Science Group.


References:

[1] NHS Long Term Plan. NHS UK.
www.longtermplan.nhs.uk/
[Accessed 25/05/2020]

[2] Access logistics hub. NHS UK.
https://digital.nhs.uk/coronavirus/access-logistics-hub
[Accessed 25/05/2020]

[3] Goldfarb A, Tucker C. Digital economics. J Econ Lit. 57(1): 3–43 (2019).

[4] Digital First Primary Care. NHS UK.
www.england.nhs.uk/gp/digital-first-primary-care/
[Accessed 25/05/2020]

[5] www.rcgp.org.uk/about-us/news/2020/april/around-7-in-10-patients-now-receive-gp-care-remotely-in-bid-to-keep-patients-safe-during-pandemic.aspx

[6] Richard E, van Charante EPM, Hoevenaar-Blom MP et al. Healthy ageing through internet counselling in the elderly (HATICE): a multinational, randomised controlled trial. The Lancet Digital Health. 1(8): E424–E434 (2019).

[7] Kovatchev BP, Kollar L, Anderson SM et al. Evening and overnight closed-loop control versus 24/7 continuous closed-loop control for Type 1 diabetes: a randomised crossover trial. The Lancet Digital Health. 2(2): E64–E73 (2020).

[8] Miller EA. The technical and interpersonal aspects of telemedicine: effects on doctor–patient communication. J Telemed Telecare. 9(1): 1–7 (2003).

[9] Hammersley V, Donaghy E, Parker R et al. Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care. Br J Gen Pract. 69(686): e595–e604 (2019).

[10] www.ohe.org/news/digitalisation-health-care-during-covid-19-consideration-long-term-consequences

[11] van Dijk, JAGM. Digital divide research, achievements and shortcomings. Poetics. 34(4–5): 221–235 (2006).

[12] Health and Social Care Act 2012. Official web-accessible database of the statute law of the United Kingdom.
www.legislation.gov.uk/ukpga/2012/7/contents/enacted
[Accessed 25/05/2020]

[13] Equity Act 2010. Official web-accessible database of the statute law of the United Kingdom.
www.legislation.gov.uk/ukpga/2010/15/contents
[Accessed 25/05/2020]

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