Opinion: Digital health: the latest iteration of medicine’s knowledge problem

When I did my residency in internal medicine and primary care a few years ago, digital health wasn’t on my radar. I didn’t get questions about health apps from my patients, didn’t talk about them with my colleagues, and certainly didn’t get any instruction about them.

Fast forward a few years, and digital health tools — by which I mean apps for detecting, monitoring, treating, alleviating, and coordinating medical conditions — have exploded, catalyzed in part by the Covid-19 pandemic and its pressures on the health care system. There are now more than 350,000 apps, ranging from behavioral health to reproductive health, sleep medicine, addiction medicine, musculoskeletal medicine, and beyond.

I subscribe to both Health Tech Nerds and Rock Health, weekly newsletters that summarize new funding opportunities in the multibillion-dollar industry of digital health, and find the field both exciting and overwhelming. I’m never quite sure which digital health apps I should “prescribe” to my patients — many of them seem like they could work wonders for the chronic conditions I commonly see, but I have no idea where to start. Which specific app should I recommend? What is the evidence? And what are other providers doing?

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National and even international regulation of health apps is a hot topic. But what I see missing are conversations about the role clinicians like me should play in this massive and confusing landscape.

In my clinical practice at an academic medical center, I’ve yet to personally discuss a digital health product with a patient, much less recommend one, or see a colleague do that. I’ve asked newer doctors what they’ve learned about digital health products in medical school, and the answer has been “nothing.” And yet, digital health apps often carry the disclaimer, “Make sure to consult your health care professional.”

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Sachin Jain, a physician and health care executive, has described this phenomenon as “the innovation bubble.” There is the “change layer,” in which visionary ideas about health care transformation flourish, but there is also the “reality layer,” in which most care is actually delivered. Unfortunately, few digital health apps are in the reality layer.

Doctors have always had to grapple with how to transfer, incorporate, and standardize new knowledge. But this task has gotten exponentially harder. First anatomy, then germ theory, the discovery of disease pathways, the creation of screening and diagnostic tests, procedures, and treatments, followed by the increasing medical complexity of chronic conditions and longevity and the rise of genetics and epigenetics. Alongside these advances are new guidelines, standards of care, quality metrics, and thousands of new peer-reviewed articles each month. Synthesizing all this would require hundreds of hours a month — time and energy clinicians just don’t have.

In 1950, the doubling time of medical knowledge was estimated to be 50 years; in 1980, seven years; in 2010, three-and-a-half years; and in 2020, approximately two months.

Historically, doctors have not done a great job with learning and adapting to all this new information. Hence the rise of specializations, which help limit how much needs to be known.

To make matters worse, not only is there so much information to absorb, but the information is often contradictory, not reproducible, and can change from year to year. The medical field has not yet figured out the appropriate use and criteria for aspirin, one of the first drugs to come into common usage. Consensus doesn’t exist over how to manage diabetes, one of the most common chronic conditions with decades of peer-reviewed research. The reasons are complex, and include the slow pace of medical research and practice, the magnitude of responsibilities and knowledge, and the lack of energy and resources to be innovative, curious, and empowered. Fortunately there are clinical decision support tools like UpToDate and medical society guidelines — both of which are my go-to sources for clinical care information — in which specialists summarize current guidelines of care.

Digital health has three key differences from prior advances in medicine that keep me up at night, thinking that we need to figure out quickly how to pop this innovation bubble. One is that digital health apps are not regulated or researched in the same way as medications and devices, making it harder to measure their usefulness and utility in familiar ways. Another is that patients can access and consume these products without needing a physician’s guidance or a prescription. This is great in terms of improving access, but is also confusing in terms of what role physicians should play. The third difference is the digital platform: its potential for scale, accessibility, and impact are enormous.

I see a few possible solutions:

  • Create a clinical support tool for digital apps, or at least incorporate digital app recommendations into existing clinical support tools.
  • Incorporate into the medical school curriculum formal lessons for navigating digital health and recommending digital tools to patients, and make this part of continuing medical education courses.
  • Creating online review systems for different apps where doctors and patients can share their experiences.

By being more actively involved in the digital health revolution, I hope that the community of providers can help improve our toolkits for supporting patients and families in their wellness and illness journeys.

Charlotte Grinberg is a physician-writer and a palliative care fellow at Beth Israel Deaconess Medical Center in Boston.

Source: STAT