The Digital Future Is Now.

Much has been written about the “techcelleration” related to the COVID-19 pandemic: 10 years of digital transformation took place in only a few months as societies locked down to limit the health impact of a new virus in our populations. Face-to-face interactions became a luxury, and even when possible, many patients chose not to expose themselves to any risk of COVID-19 transmission in the travel to and from, or at, a health care facility.

As the pandemic runs its course, and we end up with the virus endemic within our populations, what role will digital health play for the heart failure community, including patients and their health care teams? Will reimbursement remain as supportive of remote consultation and remote monitoring, or will it view this approach as a second-best option? Will clinicians and patients continue to accept virtual visits and digital tools (as part of a range of approaches), or will we return to business as usual?

To a large extent, digital technologies are already embedded into all aspects of modern life. Much of our communication and professional (as well as social) activities are done remotely on a variety of social media platforms and their associated tools, including smartphone applications (apps). Data collected in health care facilities are almost completely digital from origin to end, and they can (in theory, at least) be shared anywhere with anyone. To some, such ease of sharing is a cause of enormous concern. From the patient’s perspective, they can communicate (again in theory, but increasingly in practice) with their health care teams by many digital routes, including e-mail, SMS, message sharing apps, and virtual consultations, and they can share even large imaging data sets with anyone globally. Patients can also find other patients on social media sites and can access information (of variable quality) within a few seconds of connecting to the Internet. Not surprisingly, this wave of data is described as a “tsunami” by many in health care.

To some, these changes are to be welcomed, but to many (particularly in the highly regulated, risk-averse culture of health care) these changes are troublesome and are often either ignored or resisted.

Big Data, with high volumes, velocity, and variety of data (but with questionable veracity), is often considered either as a panacea or as the end of life as we know it—with few taking up a more balanced position. There is a concern that health care professionals will end up spending all of their time in front of a smart screen, rather than interacting with their patients and practicing the art of medicine. The ethos of medicine has developed over millennia to be that of a profession, with special knowledge and empathy, interacting with others to enhance their health and life. Is this at threat?

There is also a concern that inequalities may be exacerbated by this “digital first” approach, where those without the means to buy technology and access data on the Internet may be left behind. And what happens when it goes wrong? Who will take the blame? Over and above the concerns regarding data security, there is a fear related to “baking in” intrinsic biases and a lack of transparency or understanding of some artificial intelligence approaches. Will human cognition be left behind as we move to a digital world, where everything is reduced to remotely collected data made sense of by algorithms, but with the doctor (and patient) taking the risk when things go wrong?

These issues also apply to heart failure. Over the past decade, there have been enormous changes in how digital technologies affect heart failure diagnosis and care. Decision support is largely digital, and it is often embedded in electronic medical records in primary or secondary care. Drug interactions are flagged automatically, and prescriptions are largely electronic. Cardiac imaging often has machine learning algorithms to rapidly identify and quantify abnormalities (such as low ejection fraction), and machine learning is increasingly used to optimize image acquisition in less expert hands. The Food and Drug Administration and other regulators have approved machine learning imaging software, as well as a range of electrocardiographic and arrhythmia detection devices. Remote monitoring and algorithms to identify patients at higher risk of decompensation comprise a huge industry, although robustly demonstrating that remote monitoring is better than usual specialist care has been surprisingly challenging: the European Society of Cardiology guidelines in 2021 reflect the fact that most studies show similar outcomes rather than improvement. However, the value of such remote approaches is not challenged in terms of patient convenience and reassurance, particularly when social interaction is difficult or prohibited. There are also increasing numbers of wearable technologies available that may find a place in remote monitoring of heart failure.

Most heart failure clinics now have the options of face-to-face reviews, telemonitoring of stand-alone or implanted devices, or remote consultations and monitoring. Reimbursement changes in many countries during the early stages of the pandemic encouraged this “hybrid” or “blended” approach, and although services are now moving back more toward a 50:50 split of face-to-face and virtual care, the acceptability of virtual visits or monitoring is now high among both clinicians and patients. Most reports, including an article by Sammour et al that was recently published in JACC: Heart Failure, suggest that virtual approaches are as effective as the traditional approach.

The vision of the future remains that a person living with heart failure (and its many comorbidities) can be at the center of care—using a range of technologies (including digital health) to support their own care and stability without the need for input from the health care team—but that person is able to access that team early and rapidly should things go in the wrong direction. Such an approach was flagged as the ideal more than a decade ago in an editorial in the New England Journal of Medicine. COVID-19 has accelerated the acceptability of this approach, as we move from a more health care–centric model to a more personalized and codesigned approach to support individuals (not “patients”) to live with their chronic conditions for longer and better.

It is, of course, not just about using more and better sensors, wearables, and apps. The problem is not in the engineering or data transmission, but in making sense of the tsunami of data. How can we make better decisions with better outcomes and experience of care, rather than just more decisions? More data can lead to more health care use or much more activity but no better outcome. Plugging the data streams, with appropriate sense making (human or supplemented by artificial intelligence), into the human chain of decision making and action is essential. Too many false positive results, or too much extra work without a sense of return, mean that many digital tools are destined for only very short-term use.

The focus has to be on solving real problems, rather than developing technology “solutions” and throwing them at the wall, in the hope that they will stick. Codesign with patients (and their caregivers) is essential and increasingly recognized as a key to success. However, that codesign also has to involve other stakeholders, including the technology developers, regulators, reimbursement authorities, and policy makers.

Scientific journals, such as JACC: Heart Failure and the European Heart Journal-Digital Health, are playing their part in publicizing (after appropriate scrutiny) new digital approaches to prevention, diagnosis, risk stratification, therapy identification and testing, and communication. The rapid innovation and resilience that we have all had to show during the pandemic must persist as we move into new challenges. However, the ethos of heart failure care will remain the same, with the goal of delivering personalized care that optimizes the outcome and experience of that care. This includes more effective prevention, rapid and early diagnosis, risk stratification and therapy decision making, and monitoring (including support to self-monitor and self-manage if desired, but with rapid access to health care professionals when they can add value).

Let us use the creativity of digital innovation to codesign the future together—freed up to do what we have been trained to do and where the human touch is needed. Digital technology is intrinsically neither good nor bad—it needs to prove its worth just as any intervention does—but where it adds value and improves outcome and experience of care at a reasonable cost, we should whole heartedly support it. Where it does not, or where it may lead to less equitable and poorer outcomes and experience of care, we need to challenge and improve it.

The digital future is now, but we all need to work together to harness its potential to create a better tomorrow.