Digital health tools are getting more uptake in health care systems. One core element these companies need to address is adherence, often expressed through the user experience or engagement. In a traditional medical model ensuring people take their medications as prescribed is a critical part of supporting someone in managing their chronic condition. Some papers have been published that shed light on what adherence looks like in eHealth solutions and what health systems can look for when deciding on which solutions to purchase.
At its simplest- measuring whether a person is using a product as it was intended to be used is an essential component of the user experience if someone engages over time, it is not unreasonable to assume they are getting a benefit. A lot of metrics can be developed to map the process flow through the solution, this is easy to track- are people opening the app and where is the process do they tend to drop off? It is just as essential to understand attrition as well as usage so we can fully map why someone continues or stops using a tool.
Understanding use gets to the concept of dose. In a medical model getting an intervention, like a medication at a specific dose for a certain period can lead to positive outcomes. How does this translate in the digital space? Some solutions may only be necessary for short-term use even if long-term use does no harm. For example, someone could use a mindfulness app with tools to support sleep hygiene that helps someone through a stressful period their life if they aren’t sleeping. Once insomnia resolves they may stop using the app- is that bad? One could argue a regular mindfulness practice can deepen coping skills for life’s stresses and could lead to a better outcome over time, however, if the person has benefited and now they are back to living their lives that’s a good outcome as well.
In the traditional app world having Monthly Recurring Revenue (MRR) is a crucial metric of success that can lead to sustained growth and funding from Venture Capitalists (VC) or other funding sources. In healthcare, we want to make sure something works, it is evidence-based, has efficacy and is effective, and is seamlessly implemented into the complexity of workflows, electronic medical records, and care pathways. At some point the goals need to align as implementing these tools in healthcare has a long runway and often the funding cycles and dollar burn rates are at odds with how long it takes to get up and running in healthcare. I do believe we will need to evolve and pivot funding and implementation models so this is less of a black box process for all parties.
A recent article in the Journal of Medical Internet Research by Floor Sieverink from the University of Twente reviewed the literature on usage and adherence. The authors included 62 studies in their systematic review focusing on web-based or mobile interventions in mental health and lifestyle change support. When we examine the recommended use of solution as intended as a marker for adherence some studies showed that people could find benefit below the recommended use levels. Thresholds can be hard to establish. The more, the better would imply better adherence but the findings are mixed as many studies struggled to define the threshold for the intended use (adherence) in the first place. Some of this arises from a lack of clarity around the mechanism of action- what aspects of the solution are contributing to a positive outcome?
The authors conclude that this is an evolving field of research and caution around “more is better” for setting appropriate thresholds for use. The concept, they argue is still underdeveloped in the digital therapeutic space and more research needs to be conducted to move beyond the early definition of intended use (logins, system use, sessions or lessons completed, etc.). Like many aspects of this nascent space much more work needs to be done to determine which tools are appropriate and how best to determine their value as a service line in a complex healthcare environment.
Thanks for reading – Trina
(Opinions are my own)