The Necessary Climb Upon the Mountain of Transformation

Digital health companies, particularly mobile health apps, empower people to achieve their best health and well-being. They do this through education and information sharing, improving health literacy; increasing access to healthcare services, such as primary care and behavioral health care; and providing tools and resources for people to engage in self-care, such as improving nutrition and fitness. Digital health companies are not a recent development, but the COVID pandemic dramatically elevated the need for and importance of digital health.

Digital health companies have raised billions of dollars in the last decade, with significant investments since 2020. In 2022, digital health held strong when investment in other healthcare ventures decreased. With the ongoing provider shortage and consumer demand for more real-time, convenient access to healthcare, this trend seems unlikely to stop. Health systems are hiring from the tech world, bringing in people with technology and digital transformation expertise, and looking for digital solutions to address access to care problems.

These are all positive developments, and I look forward to this evolution of healthcare.?

First, there are some significant mountains to climb, which cannot be ignored or climbed later.

Healthcare Culture

Digital health technologies have yet to achieve the level of excellence they promised. This is, in large part, because the technology industry does not have a genuine understanding of the culture of the healthcare system. The practice of medicine is a science and an art. As a product of 10+ years of rigorous training, clinicians are often skeptical of possible technology shortcuts to replace their individual clinical knowledge and judgment and interfere with their patient relationships.

While it is true that every culture must evolve or die, in healthcare, this happens very slowly at what feels like a glacial pace to technologists (and, frankly, the patients served). While it is absolutely true that the culture of healthcare must evolve more quickly, technologists need to slow down. There needs to be a meeting in the middle. Otherwise, technology companies are delivering solutions for a problem that the healthcare system does not yet acknowledge exists or, even worse, that addresses an acknowledged problem ineffectively.

Equity

The COVID pandemic showed many, many cracks in healthcare’s armor, particularly the lack of equity within the system. Many digital health applications, especially mobile health applications, are intended to increase access, thereby addressing one equity component. However, if these applications are not developed with critical needs in mind, they will only further exasperate inequity in healthcare. These needs include an awareness of literacy and digital literacy levels, language access, disability access (including visual and hearing impairment), digital access, and platform options. While various federal laws address civil rights, such as accessibility for people with disabilities, not all equity issues are addressed in law. These are demographics of the population that digital health companies need to know, understand, and address. This is especially true if the intended product is to be paid for by public insurance programs, such as Medicaid or Medicare.

Privacy and Security

When my team and I work with digital health companies, one of our favorite topics of discussion is the privacy and security of the system. Why? Because the answer invariably is “We are HIPAA compliant.” To which we invariably reply, “Super. That’s not what we asked.” (And sometimes my colleague Tina Simpson drops in a Princess Bride quote: “I do not think that means what you think it means.”) Being HIPAA compliant, whatever that means, is no guarantee that the system (whether an Electronic Health Record (EHR) or mobile app) is private and secure, a point repeatedly demonstrated by the numerous data?breaches?within the?healthcare system. While not all digital health companies are?subject?to HIPAA, ensuring users' privacy is still a critical baseline feature of any viable offering. This cannot be done without an adequate security infrastructure and protocols. This then requires digital health companies to have a?security-by-design culture. This means that the people, processes, and technology must all be aligned to ensure the system's privacy and security to protect the user.

Quality and Outcomes

“[T]he nexus between?digital health?and?health care quality?is complex.” This is an accurate statement, not just in terms of how digital health can – or cannot – improve healthcare quality, but also in how digital health is assessing its own quality. In the U.S., we have an unruly and ineffective quality management and performance improvement approach to healthcare quality. We measure and report on so many things to so many entities in so many ways. And yet, overall, the U.S. continues to have among the worst health outcomes in the world.

Digital health companies, like EHR, population health management, and consumer-focused mobile health apps, must understand what needs to be measured, how, with what frequency, and the measurement requirement for that information. Then, there comes the Sisyphean task of clinical data exchange. In the decentralized system we have in the U.S., data exchange is complicated and, in some cases, impossible. Additionally, we often do not collect the information we need to address critical deficiencies in our system, such as ethnicity data which is necessary to address health disparities and inequity. While some efforts are underway to address these issues, we still have a long way to go. Digital health companies must be not just aware of these limitations but active participants in addressing them.

To get clinicians’ support for digital health, it is necessary to show that the technology does improve quality without causing undue burden and significant changes to their workflow. Companies must demonstrate actual improvement in consumer outcomes to get payers, including employers, to pay for mobile health app usage. For digital health to have a truly transformative effect in healthcare, this is the mountain to conquer.