Digital Platforms as a Method of Invention for Infection Surveillance

The adoption of hybrid corn by farmers throughout the U.S. Corn Belt beginning in the 1930s provides an illustrative example of how technological breakthroughs take off and spread. Several decades of prior research and development enabled corn breeders to gain unprecedented control over the heredity of a plant that had been cultivated for millennia [1]. Equipped with new methods for inbreeding and cross-pollinating seed, hybrid corn makers developed strains designed to increase resistance to disease and insects, stiffen stalks for mechanical harvesting, and serve additional purposes that vastly increased harvests. When farmers became convinced of hybrid corn's superiority over traditional corn seed they bought in and shifted their planting accordingly. However, hybrid corn was not a single invention introduced simultaneously throughout the Corn Belt [2]. Instead, corn breeders developed hybrids separately for each area, reflecting regional variations in market conditions, soil, and climate [1]. Zvi Griliches, an economist who studied geographic differences in hybrid seed diffusion, observed influentially that: “Hybrid corn was the invention of a method of inventing, a method of breeding superior corn for specific localities” [3].

Griliches' proposition that a seminal technology's ripple effects stem from its pivotal role as a method of invention is part of a broader understanding of how some new technologies become prime movers of change in specific historic eras, such as the digital transformation in our own time [4,5]. Technological changes, considered as a group, range from small, incremental advances that affect a single activity or function to far less frequently introduced General Purpose Technologies (GPTs) that have pervasive impacts on economic, social, and political structures [6]. The emergence of electricity in the nineteenth century and the advent of computerized information and communications technologies in the twentieth century are prime examples of GPTs. In keeping with Griliches' observation about corn hybridization, which was a GPT for the agricultural sector, most GPTs are “enabling technologies” that open up new opportunities rather than providing complete and final solutions [4].

New GPTs typically spawn further research and development, which improves the core technology and creates new products, processes, and practices across multiple sectors [7]. Increasingly abundant computing power and the ever-expanding set of tasks accomplished with computer assistance exemplify this GPT evolution [8]. However, the transition from one technological regime to its successor may involve a long inter-regnum in which innovation continues but the spillover benefits for one or more sectors are only partially realized or not achieved at all [7]. Economist Paul David, in a cautionary note about what to expect from GPTs, encourages close study of their history to help avoid the perils of either “undue sanguinity” or “unrealistic impatience” with respect to their trajectory and yield [7].

The recent history of wide adoption and generally disappointing performance of computerized health information technology (IT) is a prime example of a sectoral gap between initially high expectations and less than stellar accomplishments within a larger GPT wave. Health sector leaders embraced digital technology as part of broad innovation agenda, yet after many years of tool development and massive investments in electronic health record systems (EHRs), healthcare reform efforts remain largely unaffected by IT advances [9]. Still, computerization in the form of EHRs, mobile devices, and other digital platforms has achieved some notable gains and continues to hold out enormous promise as a method of invention for healthcare and public health. For example, IT-enabled improvements in healthcare information exchanges and care coordination across multiple clinical settings could yield important benefits in terms of convenience, access, quality, and cost [10]. These improvements, in turn, could provide new surveillance and response opportunities for public health agencies as they confront health threats, such as rapidly emerging infectious diseases and increasing antimicrobial resistance, which are exacerbated by gaps in care coordination and coverage [11,12].

Versatile mobile devices and ever-more sophisticated digital applications are the transformative products of a general-purpose engine, computerized information and communications technologies, operating at full throttle and serving as a method of invention. As the component parts of mobile technologies matured, they enabled advances in devices and applications, which together have spawned a “sea change in the way that people access, use, and share information” [13]. The spillover effects are myriad and multi-sectoral. In the health sector, mobile solutions include use of smartphones and tablet computing devices for communications between practitioners and patients, real-time remote monitoring, medication reminders, point-of-need testing, crowd-sourced clinical trials, and early warning systems for infectious disease spread [14,15]. Whereas much remains to be learned, developed, deployed, or adapted [16], mobile health provides an array of tools for reaching and engaging patients, and some devices already have entered the clinical mainstream [15].

Throughout the health sector, including surgery, IT advances offer new opportunities to gather patient-generated health data (PGHD), respond to patients' needs, and track patient outcomes [17]. Shorter hospital stays after inpatient surgeries, increasing volumes and complexity of procedures performed in ambulatory surgery centers, and the impact of these practice changes on when and where post-operative complications manifest themselves in episodes of care place a premium on enabling surgeons and care teams to stay connected with patients remotely. Digital photographs and other patient-reported data conveyed via smartphones are among the most promising uses of mobile technology for post-discharge surgical care [18]. Findings from an increasing number of studies provide evidence that use of smartphone wound photography for post-discharge surgical site infection (SSI) monitoring is feasible and provides advantages over more conventional approaches [19–22].

Further evaluations are needed to define the role of mobile devices better in clinical decision-making and systematically assess workflow implications, outcomes, costs, and generalizability of technical solutions [16]. However, despite open questions and practical concerns, the prevailing viewpoint is that use of smartphone photographs in post-operative care is “here to stay” [23]. The likely upshot for SSI surveillance is that mobile technology, in its current state and as it continues to evolve, will serve as a method of invention for both surgical and public health practice for years to come. The proliferation and refinement of new tools and techniques for collecting, using, and sharing PGHD will enable transformative improvements in postoperative monitoring, whether the PGHD is used to evaluate and manage individual patients or track infections and other outcomes in patient populations. The benefits for SSI surveillance most likely will include more complete identification of infections among surgical patients after they are discharged from a hospital or outpatient setting.

Important near-term steps are further integration of mobile devices into post-operative clinical workflows in accordance with best evidence and sound practices and incorporating device-mediated remote follow-up into EHRs in ways that improve the quality and availability of clinical documentation. Mobile technologies used to collect clinically relevant data will provide the broadest benefits for surgical and public health practice if the devices are treated as extensions of core record systems and not standalone tools for producing new data silos [16]. Leveraging IT advances to create new value in the health sector calls for reimagining clinical documentation and assuring that key technical and policy challenges are addressed [24,25]. As a wide variety and an increasing volume of data move to digital platforms in the computing cloud, the transformative promise of big data and big data analytics will be closer to realization in the health sector. Achieving the benefits of big data will require close attention to the production and use of small data in clinical scenarios [26], including the details of which PGHD are most valuable in post-operative care. Although the diffusion of digital platforms is worldwide, the impact on the health sector in the United States and elsewhere is likely to proceed at a pace that resembles the spread of other GPTs as they spill over into individual sectors and are adapted to meet sectoral needs. Along the way, avoiding the pitfalls of “undue sanguinity” and “unrealistic impatience” will serve us well.