Improving insights into health care with data linkage to financial technology
Authors: Becky Inkster, Peggy Loo, Bilal Mateen, Andrea Stevenson
Journal: The Lancet Digital Health (2019)

This Comment is a call to action for financial technology providers, health-care professionals, and research scientists to work together to better represent the complementary nature of health care and finance in real world and research settings. We argue that a better understanding of individuals' financial data could help health-care professionals improve care, and that linkage to information about mental and physical health could create more holistic financial support systems. We live in a so-called buy now pay later credit and consumer culture. Many people live on the edge of financial ruin, with short-term liquidity issues, and struggle to keep track of bills and other outgoings. The average UK household is 32 days from running out of money from their savings1Deadline to breadline 2017. Legal & General Partnership Services Limited, LondonMay, 2017https://www.legalandgeneralgroup.com/media/1074/d2b_infographic_2017.pdfDate accessed: June 10, 2019Google Scholar and a survey from the USA2Report on the economic well-being of U.S. households in 2017. Board of Governors of The Federal Reserve System, Washington, DCMay, 2018https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdfDate accessed: June 10, 2019Google Scholar suggested that, if faced with an unexpected expense of US$400, four in ten adults would either not be able to cover the expense or would cover it by selling something or borrowing money. A strong connection exists between money and health, even when adjusted for sociodemographic variables.3Richardson T Elliott P Roberts R The relationship between personal unsecured debt and mental and physical health: a systematic review and meta-analysis.Clin Psychol Rev. 2013; 33: 1148-1162Crossref PubMed Scopus (236) Google Scholar Particularly with mental health, we see a toxic cycle in which worrying about money can worsen mental health and mental health problems can make managing money increasingly difficult. For example, Citizens Advice (London, UK) found that 60% of their service users had received a mental health diagnosis in the past 6 months, with debt advisors reporting that 56% of users showed negative mental states that impaired their financial judgment.4Citizens AdviceSix in ten people in debt affected by mental health problems. Citizens Advice, LondonOct 10, 2014https://www.citizensadvice.org.uk/about-us/how-citizens-advice-works/media/press-releases/six-in-ten-people-in-debt-affected-by-mental-health-problems/Date accessed: June 10, 2019Google Scholar Furthermore, 59% of surveyed people with poor mental health took out credit at a vulnerable time when they would not have otherwise done so.5Money on your mindThe Money and Mental Health Policy Institute.Available from: http://www.moneyandmentalhealth.org/wp-content/uploads/2016/06/Money-on-your-mind-exec-summary.pdfDate: June, 2016Date accessed: June 10, 2019Google Scholar From a social and economic policy perspective, central bank decisions about interest rates might also affect health, because research suggests that with each percentage-point increase in interest rates, up to approximately 20 000 additional cases of psychiatric-morbidity might occur in the UK.6Boyce CJ Delaney L Ferguson E Wood AM Central bank interest rate decisions, household indebtedness, and psychiatric morbidity and distress: evidence from the UK.J Affect Disord. 2018; 234: 311-317Crossref PubMed Scopus (3) Google Scholar The link between poor health and financial difficulties is well known; however, the precise dynamic mechanisms underpinning these complex associations are not understood. Little evidence-based research exists that investigates associations between finance and health. For example, in a PubMed search for publications in English on June 11, 2019, with no start date restrictions, we identified 81 758 publications with the search term “suicide”, but only 53 when combined with “debt”. In another PubMed search using the same date and language restrictions, we found the first search result for “debt” and “mania/manic” was only published in 2018. Similar disparities exist for other health terms combined with money-related terms—eg, the search term “cancer” had 3 875 202 results compared with the search terms ”cancer” AND “debt” having 85 results, as of June 11, 2019. A barrier to creating an evidence base has been a lack of access to relevant financial data and opportunities for data linkage, especially with commercial partnerships. Financial data collection for research purposes has relied on self-report surveys and population-based measures (eg, UK Office for National Statistics benefits data). Such data lack granularity for making inferences about individual-level behaviour. Similarly, randomised controlled trials involving financial health data have reported multiple challenges, including the burden on participants when collecting data using qualitative interviews; collecting information within the constraints of primary care physician appointments; and small samples restricting the scope of analyses.7Gabbay MB Ring A Byng R et al.Debt counselling for depression in primary care: an adaptive randomised controlled pilot trial (DeCoDer study).Health Technol Assess. 2017; 21: 1-164Crossref PubMed Scopus (12) Google Scholar The financial technology (ie, Fintech) sector is playing an increasingly important role in global finance. Several Fintech challenger banks have received Prudential Regulation Authority authorisation to operate in the UK (eg, Monzo, Starling Bank). New technologies enable these disruptors to rapidly amass sufficient data to build highly granular footprints for deep financial phenotyping. Concurrently, the increase in digital health care might allow researchers to assess electronic health records on a large scale to advance investigations of health-related issues. These two digital revolutions present a timely opportunity to further innovate and combine methods of scientific investigation with real-world real-time mechanisms by which to intervene. Some challenger banks are building features (with customer focus groups) that might have potential benefits to customer health (eg, enabling self-blocking of gambling transactions). Although increased regulatory focus has been put on the treatment of vulnerable customers, whether these Fintech companies should have a duty of care to innovate in this manner to protect the general and financial health of their customers is unclear; however, new commercial incentives exist for their doing so. Being customer-needs focused differentiates new financial service propositions from the traditional product-push approach, becoming a key competitive advantage. As shown by a Morgan Stanley survey, over 80% of asset management companies believe businesses with strong environmental, social, and governance practices can have increased profitability.8Sustainable signals: growth and opportunity in asset management. Morgan Stanley Institute for Sustainable Investing and Bloomberg LP.https://www.morganstanley.com/assets/pdfs/2415532_Sustainable_Signals_Asset_Mgmt_L.pdfDate: February, 2019Date accessed: June 10, 2019Google Scholar Conversely, health-care professionals have a duty of care to ensure that interventions are ethically and robustly validated and implemented. Given this serendipitous intersection of priorities between the health-care and financial sectors, the crucial question is how one actually carries out research and acts on generated insights. Data linkage across highly sensitive domains comes with extraordinary benefit and risk, requiring stringent ethical practices that rise above mandatory legal and regulatory requirements. Before action, consideration must be given to potential unintended consequences (eg, misuse, discrimination, or misinterpretation of data) and mitigation procedures put in place. Randomised control trials are already examining potential benefits of financial incentive schemes that modify health behaviours (eg, psychiatric medication adherence9Noordraven EL Wierdsma AI Blanken P Bloemendaal AFT Mulder CL The effect of financial incentives on patients' motivation for treatment: results of “Money for Medication,” a randomised controlled trial.BMC Psychiatry. 2018; 18: 144Crossref PubMed Scopus (5) Google Scholar) despite some controversy around such approaches. Preliminary findings across several studies are encouraging but by no means conclusive, and these types of studies are time consuming and costly. By contrast, Fintech providers can use A/B-style testing to trial new features. Although these methods are agile, they lack rigorous frameworks in a health-care context. Setting the right pace for innovation is challenging, but we believe the delivery of high-quality scientific outcomes with new intervention methods is possible. Partnerships between financial and health-care services should emulate new, better frameworks for data ownership and enable innovative and more user-empowered business models. At the core of any data linkage scheme must be individual-level consent. Two general methods are envisioned. For example, the preferred method is one that preserves individual data ownership and control—eg, a blockchain-based mechanism allowing individuals to release personal health and financial information for specific purposes. The General Data Protection Regulation (GDPR) right to data portability preserves in legislation an individual's right to receive and transmit their own personal data; therefore, individuals might someday be able to create a profile of their own health and financial information. An alternative method is consent at the point of transfer of information, which could be in the form of donating ones' financial information to be linked to a static health data repository like the UK biobank, or a financial bank including consent of individual-level data linkage in their service terms and conditions. Additional possibilities for data linkage and new forms of data privacy should be discussed and debated, such as secure data enclaves, edge computing, and synthetic data. Privacy and cybersecurity considerations remain paramount. In the list of top ten sectors for data breach reports in 2017–18 generated by Kroll (a global risk solutions provider), health was named first, with 1214 incidents reported over the period.10Data breach reports in finance and insurance sectors up 74% in two years. ICC Commercial Crime Service, LondonSept 14, 2018https://icc-ccs.org/index.php/1250-data-breach-reports-in-finance-and-insurance-sectors-up-74-in-two-yearsDate accessed: June 10, 2019Google Scholar Furthermore, gathering facial and voice data as part of many challenger bank registration processes could add additional risk. Fintech is just one example of the increasingly digitalised world in which we live. As such, the case we are making here goes deeper than linking financial data to electronic health records. Individuals benefit most if attempts to operationalise the health effect of digital information are a consequence of collaborations between all parties to deliver fair and robust care, services, and interventions. The vast proportion of digital information is held by commercial entities that have different underlying motivations to health-care professionals and research scientists and operate in different legal and regulatory environments. Although we should not underestimate the challenges in undertaking any projects across these domains, the risk of not trying is that academia and health-care systems might lose their seats at the table and miss an opportunity to improve public health more holistically at scale. We declare no competing interests Data without bordersOn July 10, the House of Commons Science and Technology Committee released a report criticising the lack of political leadership in digitisation across all sectors of the UK Government. One of the reported shortcomings is the absence of a unified platform to improve data sharing across different public departments that could help improve the efficiency, cost-effectiveness, and transparency of government services. As a case study, the report highlights Estonia's single unique identifier system, which ensures that all data are shareable between departments through blockchain technology, leading to the establishment of the world's first nationwide electronic health-care record and e-prescription system. Full-Text PDF Open Access