Closing the Science-Health Gap With Technology: Evidence-Based Living.

Abstract

In the last column of Technology Today, we discussed practice–based evidence (PBE), and I promised to deliver the “what’s next” in this issue. PBE is deriving its momentum and its contributions through dramatic progress in computing power, cloud-based big data, and better algorithms. Add to this the increasing connectivity of people with technology and the next generation—evidence-based living (EBL)—is arriving.Evidence-based living is about expanding people’s self-care with current science that uses new pathways enabled by technology and information to maximize health. It is a game changer in the digital age, closing the science–health gap for people by moving necessary tools and information for health promotion and health care into homes, workplaces, schools, restaurants, vacation destinations—everywhere. This column of Technology Today examines the growing field of EBL, including implications for nurses.Most health care already occurs outside of the health care system. Unfortunately, this space is ill-equipped to support optimal health; people lack the necessary knowledge and/or skills or struggle with how to translate these into positive health behaviors, as validated by poor lifestyle choices (eg, improper diet, insufficient physical activity, smoking, alcohol abuse), which result in obesity, diabetes, heart disease, and other lifestyle-related health issues. However, health care is changing with new technology.Think about a smart home. The scale in the bathroom not only measures weight, but also the percentage of weight from fat, muscle, bone, and water.1 The digital mirror analyzes stress level, heart rate, and mood.1 The smart toothbrush measures hydration, and the microchip in the toilet analyzes urine. In the bedroom, a sleep monitor measures the sleep quality as well as variability in heart rate, breathing, and oxygen saturation.1 These devices—most of them available now—routinely transmit data to smartphones. How do we make the data derived from these devices more useful to people who want to improve their own health?In the past, evidence-based practice in episodic care was the answer, but that perception is rapidly evolving. Today, it is not unusual for clinicians to combine data derived from episodic care with current evidence. Examples include teaching patients about diet and activity to improve their health. However, using only episodic data and evidence-based advice from clinicians to change behaviors is insufficient to create significant and sustained improvements,2 and does not adequately address an individual’s unique and changing needs.Most people understand the benefits of diet and exercise. They may not always know how to readily translate these benefits to their diet preferences (eg, kosher, gluten free, vegetarian); they may not feel prepared when dining out, going on vacation, or participating in other activities that can influence their routine, food choices, and exercise options. Adding data to their records about their unique and sometimes changing circumstances is helpful, but not easily captured during episodic care. Thus, patients are using social networking sites (eg, www.patientslikeme.com) more often to find solutions for their unique health needs.Evidence-based living affords the next level of health solutions by creating new electronic pathways for collecting data and disseminating information, including individualized and actionable information as well as a feedback loop on actions taken and not taken in real time. EBL is used for assessing and monitoring health as well as providing health care as needed, where needed, and when needed. Continuing with diet and exercise as the example, apps tracking caloric intake and activity can be used to assess current behaviors while also offering recommendations based on those behaviors and providing feedback on their effects. This can be done regardless of location, unless people are located in remote areas where electronic access is unavailable.The goal of EBL is to move people from an episodic health focus to a continual health focus. By effectively leveraging current and emerging technologies, people can seamlessly blend health behaviors into the fabric of their daily lives.Evidence-based living is enabled by several different technologies. These technologies include smart sensors, artificial intelligence (AI), and the internet of things (IoT).A sensor is a device that receives a stimulus and emits a response. Stimuli come in several forms such as chemical, sound, motion, temperature, and pressure, and the response is typically electrical or optical. Sensors can be implanted in the body, attached to the surface of the body (eg, as a patch), worn on the body (eg, clothes or a watch), carried in a bag near the body, or deployed in devices (eg, voice recognition in a mobile phone).Sensors are key in capturing and connecting an individual’s biological, sociological, and psychological well-being to the digital world. They enable monitoring and detection of changes in one’s health while also allowing for reporting on those changes for analyses.3 A simple example are the sensors used in the activity monitors in smart watches or fitness armbands.Sensors also go beyond monitoring and detection to allow for treatment 24 hours per day. Consider insulin pumps: the technology used in these devices allows individuals living with diabetes to match their insulin needs with their lifestyle instead of matching their lifestyle to how well their insulin injections are working.4An advantage of sensors is that data are collected without human effort. Collection is automated through devices and therefore not dependent on people remembering to collect and input the data. Even better, data are collected in real time, thereby reducing the time to take necessary action.The amount of data being collected is increasing exponentially. What do we do with this information? Artificial intelligence holds some of the answers.Simply defined, AI is the simulation of human intelligence processes by machines, especially computers.5 Artificial intelligence is needed to help us handle the staggering amount of data being generated about people, which is more than the human brain can process in some situations.The best-known example of AI currently being used in health care is the initial use of IBM’s Watson in oncology.6 This technology rapidly analyzes data from an individual’s electronic health record (EHR) along with relevant data from both the accumulation of patient data and data from published research to identify potential best-evidence treatment plans. This powerful ability to analyze and integrate data would be very laborious and time-consuming for humans.A new application of IBM’s Watson in health care illustrates the potential of AI and its impact on nursing.7 It involves a voice-activated patient digital assistant that sits on the bedside table in hospital rooms. The AI of this technology is based on data about the hospital (eg, visiting hours and meal times) combined with patient data that could involve dates and times of scheduled tests, what pain medications have been ordered, and when the next dose should be made available. The device can also control the room’s temperature and lights by patient request. The functionality depends on what the organization builds into the AI. Patients communicate with the device and receive answers to their questions and requests without having to wait for a clinician to respond to a call light. Use of the device also decreases the amount of time staff members spends responding to call lights considering the device responds more quickly.Perhaps most important is that AI such as IBM Watson can learn. It continually tracks patient questions to build its intelligence, which allows it to offer a greater service. In other words, IBM Watson continually adds patient questions and answers that are not already in the database, increasing the amount of information provided to patients. Think about what it would be like for nurses to use AI technology and have the ability to ask a device a question and receive a recommendation.The initial reviews by oncology clinicians of IBM Watson are mixed. Whereas the delivery of data to aid clinicians (eg, laboratory test results) is not a novel idea, it is a significant next step for the technology to analyze all relevant data and render a recommendation. Clinicians are faced with either using the recommendation or questioning the potential implications if they don’t. Many of the challenges to AI are not a result of the technology, but the data that feed it, implying that there are human issues as well as human solutions.We talked about challenges with data in the last Technology Today column on practice-based evidence8 by looking at publication bias where negative results were less likely to be published. We also looked at challenges to data being gathered continuously in our EHRs. IBM Watson is using available data from publications, EHRs, and elsewhere to render its recommendations to clinicians. The quality and quantity of the data used impact the recommendations being made.It is incumbent on humans to improve data that impact health and health care, including to a large degree the practices of data governance committees, institutional review boards, researchers, publishers, and those practicing in nursing informatics, data science, and analytics. Data issues have always existed, but they become more pressing as electronic data are increasingly made available along with the technology that would allow clinicians to implement their recommendations.The IoT—also referred to in health care as the internet of health things (IoHT)—refers to the interconnectivity of web-enabled devices.9 In IoHT, the interconnectivity includes the people who are connected to the devices. Examples of current web-enabled devices include glucometers, heart rate and blood pressure monitors, and activity trackers. These devices facilitate routine, real-time data gathering, analysis, and sharing by capturing relevant data from all sensor-enabled devices connected to individuals.Those who use an activity tracker may be familiar with the concept of IoT. The tracker provides information on how well you are meeting your activity goals. If connected to the internet, the tracker may also provide the information to a person’s health insurer, which could help to reduce health insurance costs.Use of the IoHT enables more comprehensive information to be provided to individuals about their health and the progress of their health-promoting activities. Such use also enables communication with healthcare providers, allowing for early intervention in health issues when needed. The success of IoT will be determined by software applications that create tangible improvements in everyday lives.1Our personal data are becoming more readily available—sometimes without our knowledge. For example, in August 2016 a man climbed Trump Tower in New York City using suction cups because he wanted to meet with the presidential candidate.10 The police were able to take a picture of the climber and, using facial recognition software, were able to identify him. In real time, the police were able to match their data with the climber’s own Facebook data and were able to learn more about the climber and the potential threat he posed. This example illustrates how increasingly interconnected people are and how the IoT can quickly find and use personal data.Our world is evolving quickly, and sometimes subtly; we may not always notice the changes. We may see the superficial evidence of change but not appreciate the deeper meaning or the risks and benefits involved. We may be fascinated by the ever-changing smartphone features and social media such as Facebook, Snapchat, and Instagram, but we may not appreciate the health care implications of the data these applications are collecting. For example, data on dietary intake recorded by someone using a calorie-counting app may be questioned based on a picture of their meal posted on Yelp.What does all this data and connectivity mean for nursing? The most important implication is that we continue to learn about the opportunities of the digital age. We must lead the continuing evolution of the nursing profession and foster its contributions in the digital age, especially where they affect people’s health. The Technology Today column is intended to provide support in achieving this goal.As nurses continue to uncover evidence through research and creation of evidence-based practice protocols, we should continually think about what PBE would be beneficial and how to acquire it. What data do we need to combine with published research evidence to optimally care for our patients, and how can we reliably acquire this data? Similarly, as we transition patients from health care settings to home care, we need to consider the new technological pathways that provide more direct linkages and feedback loops for sustained behavioral changes. How do we include these technologies as part of the discharge planning for our patients? For example, if the reason for a patient’s hospitalization is exacerbation of heart failure related to excessive fluid intake, should we link discharge planning to apps the patient is currently using (or should be using) to help target this issue?As clinicians, we need to be alert to the need for changes in practice afforded by new technologies and seek nurse experts such as informaticists to help. If you have patients bringing in data collected from apps on their smartphone or from wearable sensors and want you to aggregate the data, consider seeking advice from nurse informaticists who can design solutions to your challenges and better enable you to help these patients.For nurse researchers, the digital landscape is limitless. The need to identify and test new technological tools and pathways that yield healthier behaviors for all people, not just patients within the healthcare system, will continue to grow. Outcomes are and will depend on the technologies used, and how well they are planned, designed, implemented, and maintained.All of us receive data about our individual health, both from internal and external sources. It could be as simple as the symptoms we experience (eg, indigestion or weight gain after eating) or it could be episodic feedback from clinic visits or hospitalizations. Imagine having health information tailored to your specific needs delivered in a way that is meaningful to you, which could then result in healthier behaviors. As a nurse, how would that care plan look? Technology and EBL are enabling us to close the science-health gap, and we are only beginning to discover its opportunities for nursing.