Abstract
Health technologies have been and shall always be an integral part of the health system. Appropriate technologies provide solutions to improve healthcare services at an affordable cost. New biomedical, bioengineering and digital technologies continue to swamp the health system and consume a major part of the health budget. National authorities should develop a policy framework that articulates needs, standards and projections of safe and cost-effective technologies in the context of local epidemiological data and the felt needs of communities. Efficient implementation of health technologies requires availability of an adequate number of skilled human resources for health and infrastructure, for maintenance and replacement or for upgradation of these technologies.
Keywords
Introduction
We live in an era of technology. No sphere of our lives remains untouched by technology. The all-pervasiveness of technology is an unending process. The way technology is progressing, soon it shall become central to the existence of human beings. As in the case of other sectors, technologies have substantially influenced healthcare over the past several decades. Most of these technologies are invisible, unrecognised and considered as an integral part of healthcare. The earliest example is the introduction of asepsis as a procedure by Lister (Ackerknecht, 1982). Asepsis in different forms continues to be the cornerstone of contemporary medical practice, having saved millions of lives and protected the health of innumerable patients till date.
Technology-driven products have had a universal impact on human health and healthcare services. These include stethoscopes, eyeglasses, X-ray machines, antibiotics, vaccines, point-of-care diagnostics and imaging equipment, to name a few. While all these technologies have played landmark roles, unrivalled results in mitigating morbidity and mortality have been produced by vaccines. Eradication of smallpox and near elimination of poliomyelitis globally would have been impossible without the availability of technology in the form of safe, efficacious and affordable vaccines (Breman, 2011). Millions of lives and billions of dollars have been saved during 2011–2020 using several vaccines all over the world (CDC, 2016).
Technology and Health
The World Health Organization (WHO) defines health technology as the application of organised knowledge and skills in the form of medicines, medical devices, vaccines, procedures and systems developed to solve a health problem and improve quality of life (World Health Organization, Health technology assessment). The Organisation for Economic Co-operation and Development (OECD) defines health technology and innovations as the application of knowledge to solve practical clinical and health problems, including products, procedures and practice styles that alter the way healthcare is delivered (OECD, 2017).
In simpler words, any activity that improves healthcare either through improving its efficacy, efficiency and safety or through reducing its cost can be broadly categorised as health technology.
A large number of technology-driven tools are continuously being produced. Some get adopted rapidly, and some carry a long gestation period. The key factors that facilitate early adoption of technologies include large unmet demand, ease and safety of application, affordability and positive perception among the prescribers and users about the technology (Fett, 2000). Successful selection and introduction of any technology in the health system depends on several factors (Stevens et al., 1997). Some of these include the time of the impact of the new technology, the size of the impact, the most significant aspects of the impact (e.g., cost, benefit, organisational aspects), the state of development of the technology and ease of its application. Health technologies can play a key role in ensuring health equity and bridging the access gap between the haves and have-nots.
Health Technology and Innovations
Health technologies and innovations are usually used interchangeably. However, there are subtle differences. Innovation in its modern meaning is ‘a new idea, creative thoughts, new imaginations in form of device or method’ (Merriam-Webster). Innovation is often also viewed as the application of better solutions that meet new requirements, unarticulated needs or existing needs of a health system. Health innovation identifies new or improved health policies, systems, products and technologies and services and delivery methods that improve people’s health and well-being. It improves efficiency, effectiveness, quality, sustainability, safety and affordability. Health innovation can pertain to any dimension of healthcare, namely preventive, promotive, curative and rehabilitative and/or assistive care. WHO advocates for extensive use of innovations to achieve universal health coverage and other Sustainable Development Goals (World Health Organization, Health innovations).
Medical Devices
Within the broad group of technologies, medical devices are an important and critical subset. According to the US Food and Drug Administration (FDA), medical devices range from simple tongue depressors and bedpans to complex programmable pacemakers, closed-loop artificial pancreas systems, in vitro diagnostic (IVD) products, ultrasound products, X-ray machines, medical lasers etc. (US Food and Drug Administration). Medical devices may be broadly defined (World Health Organization, Medical devices) as diagnostic and therapeutic equipment, instruments and supplies and ancillary equipment. These include any instrument, apparatus, implement, machine, appliance, implant, in vitro reagent, software or material intended to be used for: diagnosis, prevention, monitoring, treatment or alleviation of disease; treatment of injury or investigation, replacement or modification for supporting or sustaining life; control of conception; disinfection of medical devices; or provision of information for medical or diagnostic purposes by means of in vitro examination of specimens derived from the human body.
Medical devices do not act through any pharmacological, immunological or metabolic action on human body. This differentiates medical devices from drugs and vaccines.
Medical devices have become indispensable for healthcare practitioners as tools for prevention, diagnosis, treatment and rehabilitation and thus for the effective control of major health problems. However, the issue of rational use of medical devices needs to be addressed.
Emerging Health Technologies
Thousands of new technologies appear every year. It is not possible to describe them all. There are a few that have had a significant and long-term impact on human healthcare. Some of these are briefly described here.
Biotechnology-based Health technologies
Modern applications of biotechnology continue to find promising new uses in the medicine and healthcare field. Some of the biggest areas of application in this field are described below.
Precision Medicine
Precision medicine is an emerging approach for personalised or tailor-made treatment and prevention that takes into account variability in genes, environment and lifestyle for intended persons (US National Library of Medicine). Precision or personal medicine is based on patients’ genomics and biologicals in conjunction with their lifestyle, environment and health status. It not only improves the prediction process of a diagnosis but also, with the help of algorithms, provides options for treatment and continuous monitoring. Precision medicine is data-driven and provides doctors comprehensive patient-related information in one place, with formulas that work out averages of best results when a condition is to be addressed. Apart from data, this technology is driven through advances in biotechnology and pharmacology.
Pharmacogenomics
Pharmacogenomics is the study of an individual’s likely responses to drugs and doses and involves selection of the most appropriate, efficacious and safe personalised therapeutic regimens (US Centres for Disease Control and Prevention, 2018). While pharmacogenomic testing is currently used for only a few drugs, the field is growing very quickly. It has started moving to sub-molecular levels. RNA-based therapeutics are also being explored to modify the impact of intracellular RNAs in disease causation and treatment thereof. Some rare genetic disorders and cancers are being targeted through this approach (Bajan & Hutvagner, 2020).
Gene Mapping
Gene mapping has the potential to be used for prediction of diseases. Patients no longer need to have early symptoms to make changes to their lives. Doctors can look at the genes, much in advance and prior to development of clinical features, to determine if an individual is at a risk of developing certain health conditions, especially heredity disorders. People have started demanding to know if they have the genes that put them at a higher risk of breast cancer or Alzheimer’s disease, especially when there have been such cases among their parents or siblings. Gene mapping facilitates early management of disease even at the pre-symptomatic stage. Also called linkage mapping, it can offer firm evidence that a disease transmitted from a parent to a child is linked to one or more genes. Mapping also provides clues about which chromosome contains the gene and precisely where the gene lies on that chromosome (National Human Genome Research Institute). Genetic maps have been used successfully to find the genes responsible for relatively rare, single-gene inherited disorders, such as cystic fibrosis and Duchenne muscular dystrophy.
Biopharmaceuticals
Biopharmaceuticals are medical drugs produced using biotechnology. They are proteins (including antibodies), nucleic acids (DNA, RNA or antisense oligonucleotides) used for therapeutic or in vivo diagnostic purposes. The first such substance approved for therapeutic use was recombinant human insulin (Science Daily). Research is now being undertaken with regard to this technology to find treatments for such diseases as viral hepatitis, cancer, arthritis and cardiovascular diseases. Biopharmaceuticals have improved the way drugs and medications are developed, delivered and used. This field is bound to amplify manifold in the near future.
Genetic Testing
Genetic testing is one of the more controversial applications of biotechnology and includes two major types: one method involves the use of DNA probes with sequences similar to mutated sequences, and the other method involves comparison of a patient’s DNA sequence against a healthy person’s DNA sequence. Applications of biotechnology in genetic testing make possible determination of sex, carrier screening, prenatal diagnostic screening, newborn screening and even forensic and identity testing (Mayo Clinic). The applications are extremely broad, but the ethical aspects need further global unanimity.
Bioengineering-based Health Technologies
Rapid Diagnostic Techniques Using Advances in Bioengineering
Portable diagnostic kits that make use of the power of smartphones are becoming commoner for a variety of illnesses (DocWire, 2020). Smartphones are virtually becoming hand-held laboratories. Smart contact lenses have been developed which can sense blood glucose (Badugu et al., 2003).
Smartphones are also being used to continuously monitor electrocardiogram (ECG). The technology converts electrical impulses to ultrasound signals that are then transmitted via a smartphone's microphone (Farr, 2014). These devices shall soon come to be used on a widespread scale and facilitate early diagnosis and rapid institution of specific treatments.
Biomedical engineering has evolved over the years in response to advancements in science and technology. Some of the well-known examples include prosthetics, such as dentures and artificial limb replacements, robotic and laser surgery, implanted devices (insulin pumps, pacemakers and artificial organs), imaging methods, such as ultrasound, X-rays, computed tomography (CT) and magnetic resonance imaging (MRI), kidney dialysis, radiation therapy and numerous wearable gadgets (Dias & Paulo Silva Cunha, 2018). Medical devices can now be perfectly matched to the exact specifications of a patient using three-dimensional (3D) printing technologies. These perfectly align with the patient’s natural anatomy, thus enhancing acceptance by the patient’s body. The patient also expresses greater comfort, with improved performance and comfortable outcomes as a result.
Robotic Surgery
Robotic surgery is minimally invasive, more precise, less prone to infection and quicker to heal. Image-guided robots can now investigate lesions on the brain without damaging any of the surrounding tissue. They can shape a bone to precisely fit a prosthetic with an accuracy humans do not possess (Ng & Tam, 2014).
Digital Technologies
Digital technology refers to electronic tools, systems, devices and resources that generate, store, process and/or transmit data, including the devices such as smartphones and computers. These also include software and web-based information. Artificial intelligence (AI) and machine learning (ML) have become important parts of digital technologies. The Internet is a ‘general-purpose’ digital technology with a phenomenal impact on the way humanity works and delivers efficient healthcare services.
Health systems generate voluminous data on a continuous basis. It is estimated that at any time health data constitute as much as 30% of the world’s stored data (Huesch & Mosher, 2017). These data contain an immense amount of useful information on health and disease and on how effectively, equitably and efficiently health systems perform.
In 2017, 5 billion people had access to smartphones, and the Internet had a global penetration of 57% (Business of Apps, 2019). In 2018, 194 billion apps were downloaded, up from 178 billion in 2017 (Business of Apps, 2019). The proportion of adults seeking health information online more than doubled between 2007 and 2017 (Business of Apps, 2019). More than 165,000 apps related to health were available in 2015 (OECD, 2017). These pertained to medication reminders, mobility tracking, fertility monitoring, etc.
In spite of this, unfortunately, health systems remain ‘data-rich but information-poor’. Health lags far behind other sectors in harnessing the potential of data and digital technology, missing the opportunity to save a significant number of lives and billions of dollars. Data can be effectively used for improving patient care, managing health systems, enhancing surveillance and population health and enabling research (OECD, 2017).
As with biomedical- and bioengineering-related technologies, a large number of technologies have appeared in the area of digital sciences. A few of the important ones are described here.
Artificial Intelligence
AI is a broad scientific discipline with its roots in philosophy, mathematics and computer science which aims to understand and develop systems that display properties of intelligence (Panch et al., 2018). AI promises great benefits to the practice of medicine and to the health of populations. AI platforms are currently being developed for use or implemented in many targeted healthcare applications, including screening for risk of development of non-communicable diseases (NCDs), medical diagnosis, patient monitoring, including early recognition of impending complications, and learning of health systems (Basatneh et al., 2018). These are resulting in increased efficiency in healthcare delivery and improving the effectiveness of the care that is provided.
AI commonly refers to the computational technologies that mimic or simulate processes supported with human intelligence, for instance, reasoning, deep learning, adaptation, interaction and sensory understanding (Elsevier Artificial Intelligence Program, 2018). The interest and advances in AI applications for health have surged in recent years, primarily due to the substantially enhanced computing power of modern computers. Application of AI to improve diagnostic and therapeutic accuracy and enhance the overall clinical treatment process has been well documented (Jiang et al., 2017). AI applications have assisted doctors and health professionals in general in the domains of health information systems, geo-coding of health data, epidemic and syndromic surveillance, predictive modelling and decision support and medical imaging (Tran et al., 2019).
AI systems assist physicians through providing up-to-date medical information from journals, textbooks and standard clinical practices to ensure evidence-based patient care (Elsevier Artificial Intelligence Program, 2018). Moreover, AI systems integrated into clinical workflows help reduce diagnostic and therapeutic errors. AI has the potential to extract useful information from a large patient population to assist in making real-time inferences for health risk alert and health outcome predictions (Neill, 2013). In a clinical setting, AI tools help physicians understand complex NCDs better and more accurately evaluate patients’ status based on high-throughput molecular and imaging techniques, which at the same time reveal the complexity and heterogeneity of diseases (Krittanawong et al., 2017).
Augmented Reality
Augmented reality has been revolutionising the efficiency and cost optimisation of surgeries. The past decade’s advances in diagnostic imaging, real-time data streaming and data processing technologies have revolutionised how doctors utilise images and scans to plan for surgical procedures. Augmented reality–based headsets and solutions, which leverage two-dimensional (2D) images and other patient data to create and superimpose a 3D model of a patient’s anatomy on the patient’s body to assist in surgery, are currently being explored for increasing the success rate of surgeries (Munzer et al., 2019).
Machine Learning
ML is a sub-discipline of AI, where computers programs (algorithms) learn associations of predictive power from examples in data. ML is a specific application of AI which allows computers to learn and improve from data and experience via sets of algorithms, without the need for re-programming.
ML is most simply the application of statistical models to data using computers, which uses a broader set of statistical techniques than those typically used in medicine. Newer techniques, such as deep learning, can handle more complex data. ML expands on existing statistical techniques (Beam & Kohane, 2018) and can detect patterns that can in turn be used to formulate hypotheses. It can incorporate many variables and is generalisable across a much broader array of data types. ML has the capability to produce results in more complex situations. ML methods have been deployed in the research context in screening, diagnosis and prediction of future events.
The Internet of Things (IoT)
Medical facilities are brimming with gizmos and teeming with data, but the Internet of things (IoT) is getting all these separate elements to talk to each other, and the results have had an immediate impact, including efficient management of hospital resources. IoT can further be used to track staff, patients, devices and other assets in a critical setting (Meinert et al., 2018).
Big Data
When large volumes of data of various types and from several sources are to be analysed, ordinary computers and software cannot provide solutions. Parallel computing tools are needed to handle such data. Big data can analyse simultaneous inputs of unstructured, semi-structured and structured data. Big data ‘size’ varies from a few dozen terabytes to many zettabytes of data (Beam & Kohane, 2018). Big data requires a set of techniques and technologies with new forms of integration to reveal insights from data sets that are diverse, complex and of a massive scale.
Big data uses mathematical analysis, optimisation, inductive statistics and concepts from non-linear system identification to infer laws (regressions, non-linear relationships and causal effects). It has the power to extract information from large sets of data with low information density to reveal relationships and dependencies. It also has the ability to perform predictions of outcomes and behaviour. Big data are processed with advanced tools (analytics and algorithms) to reveal meaningful information. This is an upcoming but expensive technology with phenomenal applications in the days to come.
Electronic Health Records
Electronic health records (EHR) are defined as comprehensive interconnected databases that can capture and share a variety of information about people’s health status, their encounters with the health system, the result of all diagnostic and therapeutic interventions and, if possible, their key social and demographic parameters. Though several challenges are associated with implementing it (Friedman et al., 2013), access to EHR shall not only provide reliable services to a patient irrespective of their location but shall also result in savings for the individual, as well as for the health system. The EHR of many patients can be analysed to generate the epidemiological profile of a community and trace the spread of diseases.
Telehealth and Telemedicine
Advances in video conferencing technology, combined with the expansion of mobile Internet connectivity and the proliferation of wearable devices, have made telehealth one of the most important trends in medical technology in recent times. Utilising a mobile device and a two-way camera, care providers can have one-on-one encounters with patients from a distance. Earlier, these patients were usually either in rural areas or unable to secure transportation to a physical facility. However, now telehealth is gaining foothold in urban areas, with substantial positive implications for patients and the health system.
For older people living alone, regular check-ups can help avoid strokes, heart attacks and other adverse events and, logistically, reduce the risk of exposure to other diseases. As the technology improves and incorporates augmented and virtual reality, usage could graduate from simple virtual check-ups to comprehensive evaluation and management of patients. Even in global emergencies, such as a pandemic, routine medical care can be provided through telemedicine. The COVID-19 pandemic is one situation where telemedicine is increasingly being used to consult a physician remotely without having to physically be present. Government of India has recently issued guidelines on the use of telemedicine during the pandemic COVID-19 (Ministry of Health and Family Welfare, 2020).
Telemedicine is growing rapidly, and according to industry projections, the global compounded annual growth rate of telemedicine is between 13% and 27%, with valuation growing to over USD 20 billion over the next several years (Waller & Stotler, 2018).
Blockchain
Blockchain is a new and trending word in the field of information technology. A blockchain, originally block chain, is a continuously growing list of records, called blocks, which are linked and secured using cryptography. Each block primarily contains a hash pointer as a link to a previous block, a timestamp and transaction data. This technology would help sharing of medical data between facilities, and between scientists, for effective treatment without any fear of a security breach. Blockchain is built around a system of currently non-hackable cryptography and facilitates keeping a distributed ledger of vast amounts of information (Leeming et al., 2019).
Managing Health Technologies
Management of health technologies is critical. While technologies provide huge support in improving a health system, these can be extremely cost-intensive too. In OECD countries, an average of 35% of the budget for the health system is consumed by technologies. In addition, there is an annual increase of around 1% in the investment on technologies (Marino & Lorenzoni, 2019). At the same time, the measurement of the impact of technology as a driver of healthcare expenditure is complex, since technological effects are closely interlinked with other determinants, such as income and the composition and health status of a population.
To ensure access to appropriate medical devices, proper assessment, management and use of medical equipment must be considered. The management process begins with understanding the needs of a country, region, community or facility and ends with commissioning.
The first step in health technology management is health technology assessment (HTA). HTA refers to the systematic evaluation of properties, effects and/or impacts of health technology. It is a multidisciplinary process of evaluating the social, economic, organisational and ethical issues of a health intervention or health technology (World Health Organization, Health technology assessment).
Appropriate Health Technologies
Health technologies are all-pervasive and can be a big drain on a health system. The concept of appropriate health technologies to strike a balance between available resources and emerging needs has been doing the rounds. Appropriate technologies are defined as those that are scientifically valid, socially acceptable and universally available to all individuals and families in communities at an affordable price (World Health Organization, 2001).
More than 8,000 generic medical-device groups are in daily use across the world (World Health Organization, 2007). Accordingly, each country needs to strike a balance between the largely supply-driven market in devices and the needs of the health system.
Key Elements in Managing Health Technologies
Needs Assessment
Needs assessment for technologies should be based on epidemiological and demographic data, indicators of availability and rates of usage of medical devices in healthcare facilities, staff capabilities and the resources available for procuring and operating these devices. Such needs assessments should consider national and international norms, standards, guidelines and the conditions in which they would be used. Resources should not be wasted on technologies that do not meet priority needs or are too complex, incompatible with the existing infrastructure and services or too costly to maintain in service.
Quality and National Standards
Technologies of poor quality not only are a waste of finite resources but may also cause harm to patients through generation of wrong diagnoses or irrational treatment modalities. The consequences can be severe. For essential technologies, countries must have national standards of quality, and all technologies should be procured only if compatible with these standards. There should be strong institutional and regulatory support to assess the quality of technologies and measure their performance standards.
Safety
The use of medical devices carries a certain risk for patients, medical personnel and the general public. In WHO’s resolution WHA55.18 (World Health Organization, 2002), the World Health Assembly emphasised the importance of improving patient safety and quality of care through strengthening the science-based systems used to assess and monitor medical equipment and technology.
Sustainability
Ensuring the sustainability of services and maintaining access to appropriate medical devices must remain important considerations. This management aspect needs sound mechanisms for planning and assessment, acquisition, operations and maintenance. Moreover, the health system also needs to be able to identify obsolete devices that could be replaced by new devices that may have a greater impact on public health.
National Policies and Effective Regulatory Mechanism
Well-defined national policies and guidelines are essential, and these must cover all aspects of health technologies. These require regulatory mechanisms to support policies and provide technical support in ensuring quality technologies, including medical devices.
Research and Development
Developing new technologies and improving the available technologies are continuous processes. Researchers must be encouraged to develop appropriate technologies that promote the health of the population, ensure equitable access to these technologies and promote the sustainability of the national and local health systems.
Conclusions
A world without technology is unthinkable. Health systems cannot escape the influence of these technologies. It is also difficult to keep pace with the rapid advances in biomedical, bioengineering and digital technologies. Selection, utilisation and maintenance of technologies to have the best return on investments in these tools should be done through a policy framework, keeping in mind access to and safety, quality and cost of technologies. National authorities, with assistance from various international development partners, should take a lead in this endeavour. Providing the best of health system–related technologies to communities on a sustainable basis is a huge challenge that must be met in the most cost-effective way. A national policy on emerging health technologies is the need of the hour.
Footnotes
Declaration of Conflicting Interests
Funding
The authors received no financial support for the research, authorship and/or publication of this article.