The digital health “revolution” appears to be well under way. According to a recent survey by the American Medical Association, the vast majority of physicians believe that adopting digital health tools will improve their ability to care for their patients.
The American Medical Association (AMA) reported that physicians want new technology to fit into existing systems. Importantly, physicians wanted to be part of the decision-making process when it comes to new technology.
The main requirement of new digital tools – including telemedicine/telehealth, remote monitoring, mobile health (mHealth) apps, and wearables such as activity trackers – was to help physicians with their current practices, rather than radically change what they do and how they do it.
Why are some healthcare professionals becoming disenchanted about the development of digital healthcare and its use in daily clinical practice? Do they view it as being based on little or no evidence?
In a recent article in NEJM Catalyst, the authors note that “fewer [digital health] products than expected are being deployed in real-world clinical settings.” This may be related to complaints that in practice, these products have failed to deliver on the promise that they will lead to improved quality and outcomes and reduced costs in the management of chronic diseases.
For instance, the uptake of wearable sensors into routine practice for monitoring patients with chronic diseases has been less than anticipated. These devices transmit real-time data to the healthcare provider (HCP) using a patient’s smartphone or tablet, and in studies their use has been linked to improvements in a variety of outcomes, from quality of life to improved survival.
Until recently, however, it has been difficult to duplicate these findings in clinical practice, cardiologist and IT researcher Lee R. Goldberg, M.D., of the University of Pennsylvania, told a recent meeting of the American College of Cardiology (ACC). Some studies even reported increased costs (of utilization), no impact at all, or even harm, he added.
Physicians also say they have found that managing the data and incorporating them into clinical practice presents a significant challenge. They are also faced with patients who use their own apps and sensors – many of which are untested or unproven.
“From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality, [these products are] the digital snake oil of the early 21st century.”
James L. Madara, M.D., CEO of the AMA
“More and more we’re seeing digital tools in medicine that, unlike digital tools in other industries, make the provision of care less, not more, efficient,” Madara added.
Increasingly, disappointment with digital health is linked to a cultural barrier that exists between the technology entrepreneurs, investors, developers, and practicing physicians. Development of the technology shows “a shocking lack of focus on the place where healthcare takes place,” John S. Rumsfeld M.D., chief innovation officer of the ACC, told the society’s 2017 annual meeting.
The main reason for this may be the lack of involvement of medical professionals in the development of some digital tools. In 2016, 85 percent of companies that publish medical apps said they consulted with HCPs in-house or externally, which represented a drop of 11 percent from the previous year. Furthermore, 11 percent of companies said that they did not work with HCPs at all.
“Unfortunately it often takes the critical eye of a physician to judge whether there is a credible level of evidence for an app or whether it is just a bunch of hocus pocus,” noted David M. Levine, M.D., primary care physician and researcher at Brigham and Women’s Hospital and Harvard Medical School, both in Boston, MA, while speaking with Medical News Today.
Critics say that as a result of the failure to consider what may be of most value to physicians, many existing digital tools “address health issues in piecemeal and haphazard ways.”
Many apps focus on a single disease, whereas patients with the greatest need have multiple chronic conditions. A senior with multiple chronic conditions could end up with 20 different apps on their phone, thinking that that is helpful, Dr. Levine pointed out. “This is very antithetical to the way PCPs [primary care providers] think,” he said. “I believe that people are going to start moving toward holistic approaches,” he predicted.
Apps for the management of chronic diseases are mainly focused on diabetes, obesity, hypertension, depression, bipolar disorder, and chronic heart disease, but high-quality apps for use in other chronic conditions, such as rheumatoid arthritis and pain, are lacking.
Much of the new digital health technology, especially mHealth apps, lacks an evidence base. Commercially successful apps do not necessarily have medical value for physicians to apply to decision-making for patient evaluation, diagnosis, treatment, or other options. For this reason, many PCPs are cautious about using them.
“It is very difficult for a PCP to know what is a good app and what is not, which ones are evidence-based and which one has been validated. I don’t want to introduce a new intervention to one of my patients unless I know there is evidence that it works […] it’s the same as of medication.”
Dr. David M. Levine
Digital health products that do show impressive results in clinical trials often fail to be adopted into clinical practice. This is because clinical trials are conducted in highly controlled environments, which make use of tools such as training, close monitoring, and payments to ensure that patients use the technologies appropriately. This rarely exists “in the real world,” according to Joseph C. Kvedar M.D., vice president of Harvard-associated health technology company, Partners HealthCare Connected Health.
Digital health products designed for the prevention or treatment of chronic diseases mostly do so through changing patient behavior. In order to be successful, patients need to be highly motivated. Digital companies should focus on patient engagement, Dr. Kvedar advised.
A big problem for current practice is that many digital health tools do not connect with each other. Interoperability – that is, systems and devices exchanging data and interpreting the shared data – “therefore remains largely unattainable.” Integration of new technologies is very important, Dr. Levine stressed – particularly development of technologies that are more easily incorporated into the electronic health records (called “Plug and Play”).
“We want it to all be visible to our entire health team so that anyone can log into it and it is all in one place,” Dr. Levine said. Currently, most of these apps create their own platform with their own set of log-ins and their own security issues and alerting issues. Connectivity is a big issue for the future because “oftentimes that is what keeps us from using some of these digital health solutions now,” he said.
Digital strategies have been compared to complementary medicine in that neither of them appear in clinical guidelines. Few professional medical organizations have tackled digital healthcare in their guidelines, but in 2016, the AMA issued guidance on the safe and effective use of mHealth apps and other digital health devices, such as trackers and sensors.
The AMA and AHA, together with the Healthcare Information and Management Systems Society and digital health nonprofit DHX Group, have set up an organization called Xcertia, dedicated to improving the quality, safety, and effectiveness of mHealth apps. Xcertia will offer guidance for developing, evaluating, or recommending mHealth apps, but it will not certify them.
How will physicians be able to choose the most appropriate technologies for their practice in the future? Perhaps independent organizations will test apps in collaboration with practicing physicians, producing online recommendations. One suggestion is that professional medical associations produce app “labels,” listing the characteristics of, and warnings about, each app for both patients and physicians.