The good news is the rate of publications in digital health has increased steadily in the past three years, this adds to our broad understanding of where digital health can complement health care by supporting people in their health. Many papers are opinion pieces that also play a role in continuing to hold the discipline to a standard it must strive to meet if it is going to have broad uptake in healthcare.
A new perspective by Simon Rowland and colleagues from Imperial College London published in Nature Digital Medicine queries the clinical value of digital health. Using the World Health Organizations (WHO) definition of mHealth- that being “medical and public health practice supported by mobile devices” the authors delve into the current state of mHealth.
In the USA, over 80% of people own a smartphone, globally, that number reaches 2.5 billion (out of 7.7 billion people). The potential to support more people in monitoring and and managing their health is enormous but remains a challenge to harness. The authors used the UK’s National Institute for Clinical Excellence (NICE) categorization of apps to determine both the levels of evidence an app may be leveraging and what aspect of clinical care an app may supporting. Growing numbers of people are using these tools to self-triage a la “Dr Google” to determine what action they may need to take via symptom checkers which are the most used kind of app in the diagnostic category. While data shows in emergency cases guidance was appropriate in 80% of cases. For non-emergent cases that fell to 34% for triage and 55% for diagnostic accuracy, a considerable drop in the quality of guidance someone is looking for- how is the end user meant to determine the quality of the advice given? This aspect is troubling as it could lead to someone taking steps that would worsen their health or lead to even more inappropriate use of already scarce resources. As another example, using photographs alone as a stand-alone diagnostic tool has not achieved a clinical-grade standard of accuracy that would replace a clinical consultation. Bottom line, the potential remains high, but the gaps remain significant.
A burgeoning area of app development is supporting behaviour change. In this space, apps can provide ongoing guidance and support for an individual who is working on creating healthier habits. The literature is clear there are no quick roads to success and success is more at the pace of a tortoise than a hare as the old adage goes. This can be frustrating. As humans we want to see tangible results for our efforts and often change seen as a black and white mentality of success or failure versus the more meandering path of practice and revise. Behaviour change apps can offer continuous self-monitoring, personalized goal setting, linkage to sensors and wearables as well as offer insights on progress toward a long term goal to keep someone engaged and on the long path to change. In this arena, we have stronger evidence that app-based solutions can support weight loss, blood pressure management and improvement in physical activity levels when apps are optimally used.
The newest category of apps are digital therapeutics- these tools have translated an evidence base for a clinical condition and have reliably demonstrated changes in established clinical endpoints. Some of the most substantial published data in this area are in mental health, specificically, solutions that support cognitive behavioural therapy (CBT) to address depression and anxiety.
Apps can also be used to deliver education regarding a clinical area and can be paced to whether someone is newly diagnosed to bring them along a learning curve, or if they have established disease. There is also a role for improving self-management of conditions via education. Variation in the depth, breath and quality of these apps remains substantial.
Source: DOI https://doi.org/10.1038/s41746-019-0206-x
In the table above, the authors provide some guidance on areas for future development and focus. With rare exception, the potential for these solutions to meet a clinical-grade quality is high. Still, efforts to deliver on this potential must accelerate in this decade and must also consider data use, privacy and transparency as part of the user experience. We have far too many examples of where things have been less than optimal in this space, if consumers and health systems are to more fully embrace digital health tools, how they are developed needs to also start with transparency and integrity. This also calls for founders and funders to infuse the evidence base in their products but also push on the current state so we can realize new value in the digital age. Today, we grapple with far too much noise to hear the signal and the viability of digital health hangs in the balance.
Thanks for reading – Trina
(Opinions are my own)
WHO. mHealth: New horizons for health through mobile technologies: second global survey on eHealth. Healthc. Inform. Res. https://doi.org/10.4258/hir.2012.18.3.231 (2011).
Rowland, S.P., Fitzgerald, J.E., Holme, T. et al. What is the clinical value of mHealth for patients?. npj Digit. Med. 3, 4 (2020) doi:10.1038/s41746-019-0206-x