Healthcare professionals’ use of remote consultations, electronic prescription services and other digital health systems has grown during the pandemic, as has investment in these technologies by governments and the private sector. It is unclear whether these trends will continue beyond Covid-19.
Covid-19 has increased the adoption and acceptance of ‘digital health’ systems, including telephone appointments with GPs, wearable health monitoring devices and electronic prescription services. For example, the NHS app was used by under 200,000 people in December 2019: a year later, this had increased 912% to nearly two million.
The growing use of digital health has been driven by the need to meet resource challenges in healthcare systems – many of which have been augmented by the pandemic.
For example, virtual consultations minimise the risk of Covid-19 transmission by reducing physical contact (Monaghesh and Hajizadeh, 2021). As the pandemic forced healthcare professionals to focus resources on older people, shielding patients and those with poor mental health, face-to-face consultations for others were reduced (Murphy et al, 2021).
The expansion of these technologies has increased interest among policy-makers and private organisations (such as health technology start-ups) in improving digital health infrastructure and boosting innovation.
Nevertheless, evidence is scant on whether the increased adoption of digital health will be sustainable in the long term. Similarly, more work is needed to manage the associated problems, such as heightened cybersecurity risks and increased inequality as marginalised groups are less likely to have access to digital health.
How has Covid-19 catalysed changes in digital health?
The use of digital health has been scaled up as a result of Covid-19. While digital health applications are not new, the pandemic has put technologies for ‘telehealth’ and mobile app-enabled healthcare services in the spotlight (Budd et al, 2020). In this article, we focus on the tools and systems that existed prior to the pandemic (for example, teleconsultation, telemedicine and wearables) and not those invented as responses (such as contact tracing apps).
Since the start of the pandemic, there has been a surge in the numbers of visits to NHS websites, users of NHS 111 online, prescription requests submitted through the NHS App, and use of electronic prescription services (NHS Digital, 2020).
The NHS website, ordinarily visited around 30 million times a month, had a record 120 million estimated visits in March 2020. Similarly, the number of NHS login verified identities increased by 660% over the course of 2020 from around 238,000 users to over 1.8 million.
Further, a longitudinal study analysing the use of remote consulting in UK primary care finds that in April 2020, 89% of GP appointments were conducted by telephone (some of this includes video consultations due to GP coding practices), in contrast with only 31% in April 2019 (Murphy et al, 2021).
Figure 1: GP and nurse/paramedic consultations per 1,000 registered patients, February to July 2019 and February to July 2020
Source: Murphy et al, 2021
The increased use of these technologies as a method to deliver healthcare is expected to bring benefits. These include greater access for patients with low mobility or living in rural areas, faster dissemination of medical information, efficiency gains from reduced waiting times and travel costs, and reduced errors (Polityka Insights, 2020; Centers for Disease Control and Prevention, 2020).
In the UK, responses to Covid-19 resulted in a rise in demand and corresponding use of digital health. Consequently, a ‘digital first’ approach was adopted in primary care settings. The British Medical Association (BMA) published guidelines advising doctors about receiving equipment like laptops and providing video consultation for patients in primary and secondary care (for example, see guidance from the Royal College of Ophthalmologists, 2020).
The guidelines also provide a range of resources to help care-givers to optimise video, phone and online consultations for triaging and managing patients remotely (BMA, 2020).
NHS Digital experienced an explosion in demand for its services – from ordering repeat prescriptions to booking and cancelling GP appointments (Carding, 2020; NHS Digital, 2020).
As a result of the expansion of electronic prescription services – to reduce the need for face-to-face contact and unnecessary travel – by April 2020, 86% of prescriptions dispensed within primary care in England were processed electronically, an increase of 18% compared with the year before (NHS Digital, 2020).
This potentially resulted in an efficiency gain in primary care, as a study estimated that with optimised electronic prescriptions, the number of doctor consultations can increase by 0.14 per capita in the UK (Polityka Insight, 2020).
In France, the pandemic compelled the March 2020 establishment of Decree No. 2020-227, which simplifies the legal framework for teleconsultations (Légifrance, 2020). This widened the range of options allowed for video communication platforms to include Skype and Facetime. But while it increased access, there were security concerns related to patients’ medical data expressed by the legal community (Kadar and Gaillard, 2020).
In Germany, while video consultations with doctors are historically unpopular among both licensed doctors and patients, by mid-2020, a survey by the Mannheim Institute for Public Health revealed that half of all doctors in the country offered video consultation hours and another 10% planned to offer it soon (The Local, 2020).
The increased acceptance has also been fostered by Jens Spans, the German health minister, who has been pushing for digital health investment. His measures gained wider acceptance in the middle of the pandemic. Under the Hospital Future Act (KHZG), the German government co-invested €4.3 billion to boost hospital information technology infrastructure and support digital health innovation (birkleIT, 2021; Healthcare IT News, 2021).
While the pandemic has resulted in virtual care and telemedicine becoming more established components of care delivery in the UK and continental Europe, there is as yet no reliable evidence on their long-term sustainability. Similarly, continued investment in digital health is not guaranteed.
How have digital health businesses changed as a result of Covid-19?
While many other sectors have taken a hit during the pandemic, the global market for healthcare technology has been an exception.
In the UK, investments in digital health have followed an upward trajectory, with the highest number of deals recorded in 2020, suggesting the pandemic’s contribution to bringing more players into the sector. While the highest recorded amount raised was in 2019, this was mainly driven by the major player in the UK health technology landscape, Babylon Health, receiving the largest investment of the year – over £380 million (Beauhurst, 2021).
Figure 2: Number of deals and size of investment raised by e-health companies
Source: Beauhurst, 2021
Private firms have benefitted from the framework and the increased digitalisation of the health system. Doctolib, a French start-up focusing on scheduling and booking management for healthcare practitioners, claimed to have more than 2.5 million virtual consultations on its platform by April 2020, an increase of about 30% from the previous month (HIT Consultant, 2020).
Germany experienced a similar trend in its digital health system. Prior to the pandemic, it did not play a considerable role beside fitness and wellness apps – digital tools were not being used for diagnosis or treatment (Healthcare IT News, 2021).
Start-ups working in this area have also pivoted their offerings to serve the increased demand from companies, universities and other institutions that are seeking to address the changing needs of employees, students and community members due to Covid-19 – for example, related to mental health and teleconsultations (HelloBetter, 2020; Sifted EU, 2020).
Caspar Health, a start-up providing digital rehabilitation solutions, added 70 more clinics to the existing 100 in their network after the pandemic hit (Health Innovation Hub, 2020). This is further supported by the Health Innovation Hub’s published list of trusted telemedicine services as early as March 2020, providing doctors’ practices with information such as costs, reimbursement policy, functionality and prices. This significantly increased the clinical practices’ ability to integrate such services at low cost (Healthcare IT News, 2020).
While it is apparent that in the UK and comparable European countries like France and Germany, the use and acceptance of digital health platforms have accelerated during the pandemic – and thus have attracted more investments for digital health companies – whether this will be sustained in the post-pandemic era remains to be seen.
Does the evidence point to a lasting change?
While trends show increased uptake of digital health tools and innovations, as the pandemic is still unfolding, existing studies conclude that it is too early to understand its long-term impact on adoption and implementation worldwide (Budd et al, 2020; Pérez Sust et al, 2020).
There are also possible risks that are associated with rapid change of the kind seen in the uptake of digital health services. For example, symptoms that might be captured during an in-person appointment may be undetected in remote consultations.
For people with certain long-term conditions or mental health problems, this would also mean reduced access to in-person social groups. Physicians may also experience burnout from excessive use of digital health tools.
Rapid integration of this technology may also result in inadequate data security infrastructure (Hutchings, 2020; Brassel et al, 2020). Indeed, in the UK, the new GP patient data extraction scheme – through which NHS Digital collects data on treatments, referrals, appointments and patients’ medical histories – has raised concerns. One petition against the initiative currently has over 222,000 signatories.
In addition, the imaging and diagnostics tools that are increasingly being adopted may have produced overly optimistic diagnoses. This is for reasons such as inappropriate use of data and ‘overfitting’ models, which mean that the tools are likely to be reporting results based on random errors rather than established relationships within the data (Wynants et al, 2020). This can give false reassurance to patients and may ultimately put lives at risk.
Although improvements can be made by inputting more data to ‘train’ machine-learning algorithms, which enables results to be produced with more confidence, this demonstrates that many digital health tools have not been developed sufficiently to use in real life scenarios (Peek et al, 2020).
A UK-based digital health provider, Babylon Health, claimed that their artificial intelligence-supported diagnostic and triage system outperformed doctors in an examination. Yet this was based on a study with methodological bias, in which data were not entered by intended users but by doctors who may be able to predict the results. This does not accurately show how well the tool will perform in a realistic situation (Fraser et al, 2018).
With reports of inaccurate or misleading information, the quality and reliability of the rising number of mental health and wellbeing apps have also been called into question. For example, suicide prevention apps have given wrong information and directed patients to non-existent helplines. ‘Prank’ blood pressure apps with a reach of over two million users have also given random numbers as blood pressure readings (Inkster et al, 2020).
This highlights the need for more stringent due diligence efforts, particularly as the growth of these platforms means that more unvetted tools and apps are being made available to the public. There is currently a lack of national governance and regulations for digital health products, but this may be required or demanded by users in the future.
Further, as app usability issues arise, users may turn their backs on these digital tools (Fraser et al, 2018; Torous et al, 2021). A survey seems to support this possibility, revealing that while 0% of investors think that customers will scale back digital health use to pre-pandemic rates, 33% of users and 27% of companies believe that usage will normalise to pre-pandemic rates (Lovett, 2021).
In addition, a report by Allied for Startups DTx reveals that founders of digital health start-ups see a lack of clarity around regulations on medical devices and software. And they would like a more differentiated regulatory approach based on types of digital health products or services (Giedraitis, 2020).
The long-term viability of digital health delivery has also been challenged on financial terms. A study by Imperial College London’s Institute of Global Health Innovation (IGHI) points out that new digital technologies generated during the pandemic are the result of mobilising emergency funds as well as other government funding, rather than equity investment. With current digital health services being supported by temporary funds, they will remain unsustainable solutions unless permanent changes to incentives and reimbursement are in place (Imperial College, 2021).
The views of medical professionals on the use of these technologies in the long term is also varied. Some clinicians report that they would like remote consultations to continue to be offered as an option, while others think that previous structural barriers to healthcare digitalisation will return after the effects of Covid-19 are reduced, eliminating the gains achieved during the pandemic (Peek et al, 2020).
Current digital solutions deployed rapidly in response to the pandemic may also exacerbate existing health inequalities (Porter, 2020). People who are less well-off or in vulnerable communities may have restricted access, as well as limited technological literacy (Crawford and Serhal, 2020; Hutchings, 2020).
While the current situation lends itself to increased use of digital tools in care provision, in particular for reducing the risk of infection with Covid-19, the long-term digitalisation of all levels of healthcare delivery is more complex.
At present, information flow and digital tools are fragmented across different types of technologies and are specific to certain health behaviours. For example, technology for physical activity is different to prescription monitoring apps. This creates difficulties for clinicians and policy-makers to apply a suitable body of evidence to support wider digital health implementation (Ross et al, 2016; Milne-Ives et al, 2020).
What key activities and research are in progress?
The World Health Organization (WHO) is leading a series of virtual roundtables about digital health involving civil societies, development agencies, private sector organisations, academia and other interested institutions (WHO, 2020). These are aimed at accelerating digital transformations of healthcare, enhancing collaboration and partnerships among stakeholders in global digital health.
Despite limited evidence about Covid-19’s short- and long-term effects on digital health, there is a growing consensus that the digitalisation of public health measures and care delivery is highly likely to increase in the near future, at least in the UK and continental Europe.
The expectations of both patients and healthcare professionals are also likely to change to demand more convenient, safe, and efficient care, as services like telehealth become more embedded in their health experiences.
Ensuring the sustainability of the current growth in digital health will require public and private stakeholders to cooperate in setting guidelines and securing investment to support wider, regulated and safe use of digital technologies in healthcare.
Where can I find out more?
- Covid-19 and digital health start-ups: An overview: Report by Allied Startups DTx consisting of analysis from various digital health start-ups’ founders about their contribution to Covid-19 solutions, challenges faced and the future of digital health.
- Global Digital Health Index (GDHI) is an interactive web-based resource that aims to track, monitor and assess the enabling environment for digital health throughout the world.
- Embracing digital: is COVID-19 the catalyst for lasting change? A report on the current digital health uptake during the pandemic and discussion of the barriers to long-term digital health transformation.
- Guideline on digital health interventions: Ten ways suggested by the WHO that countries can use digital health technologies.
Who are experts on this question?
- Indra Joshi, Head of Digital Health and AI for NHSx
- Harold Wolf III, President and CEO of the Healthcare Information and Management Systems Society (HIMSS)
- Sylvia Thun, Director of eHealth and Interoperability at Berlin Institute of Health (BIH)
- Henrik Matthies, Managing Director of Health Innovation Hub (HIH)
