Even as the digital revolution sweeps through our daily lives, our interactions with the U.S. health care industry have changed very little. Increasingly, people are asking why the smartphones and computers that enable us to get directions, transfer money, or book a vacation are unable to also help us answer routine questions about our health, solve our health problems, and guide us through the maze of the U.S. health care system.
Imagine you have an itchy rash that started a week ago and is now spreading. You call your doctor, but the next appointment isn’t for another two weeks. The local retail clinic is closed, and an emergency room visit will cost more than $100. Perhaps you turn to family or friends. Or maybe you simply hope for the best.
Now imagine there’s an app available for a smartphone or computer that’s designed to help people deal with health problems, whether large or small. Using this “digital health advisor” (DHA), you could describe your rash and even include a picture of it. The app asks you a few more questions and then combines your description with data from your electronic health record, your pharmacy, and a database of current medical knowledge.
"One can easily imagine the convenience, affordability, and peace of mind these digital services might offer. Yet technology entrepreneurs don’t seem to be making much progress yet."
Using its built-in decision-support tools, the DHA is able to tell you that a medication you recently started on is the likely cause of your rash. First, the DHA instructs you to stop taking the medicine and advises you to monitor for other symptoms that might indicate a more serious problem. Next, it notifies the prescriber’s office, requesting that it call you as soon as possible to recommend a different drug.
This example illustrates just one of the many ways in which a DHA might be helpful. It also could answer routine questions; streamline everyday interactions with doctors’ offices, pharmacies, therapists, and other parts of the health care system; and empower people to achieve their health goals by delivering personalized coaching on diet, exercise, and sleep. And by informing users about health insurance options, available local providers, and prices for services, the DHA also could help people select the most appropriate health plan, schedule visits, shop for the least costly medications or lab tests, arrange for home care services, and manage deductibles.
One can easily imagine the convenience, affordability, and peace of mind these digital services might offer. Yet technology entrepreneurs don’t seem to be making much progress yet. To be sure, there are now apps providing general information about medical conditions or treatments, wearable biometric sensors, and telehealth tools that enable virtual office visits. But none of these digital tools draw on peoples’ medical histories, needs, or preferences and none offer the comprehensive services of a DHA.
We believe four main factors are inhibiting progress toward a comprehensive DHA:
- technical challenges
- lack of clear business models
- absence of policies to guide development of DHA services and ensure their quality
- cultural gaps between health care providers, the consumer digital industry, and the public.
Though much remains to be solved, the technical hurdles impeding development of a digital health advisor are falling away rapidly. Hardware, sensors, software, digitized health data, networking, and ample computing power are now widely available and affordable. In many industries, product developers are producing seamless real-time digital experiences for consumers, and there is no reason to expect they cannot do so in health care.
To be sure, machine-learning capabilities will be challenged by the inherent complexity and uncertainties of medicine and human physiology, as well as incomplete digital health data and the volume of such data. But computers are already beginning to take on complex tasks like driving an automobile in traffic. With the right data, it seems likely that computers can effectively assist many decisions that currently require professional input.
Sustainable Business Models
A digital health advisor will be expensive to build and maintain. Moreover, the revenue stream to support DHA services is unclear under the still-dominant incentives of fee-for-service payment. Providers working under fee-for-service contracts have little incentive to invest in DHA services if they reduce the number of face-to-face visits or tests for which they can bill. And the patients likely to benefit most from DHA services, including those with serious health conditions and the frail elderly, may be least able to pay for them. Without a clearer set of business cases, investors are unlikely to provide the capital needed to build the DHA.
"As value-based payment spreads, more providers are being held accountable for both their total spending and their quality of care, even taking on financial risk for spending targets."
However, the business case for DHA services may get stronger. As value-based payment spreads, more providers are being held accountable for both their total spending and their quality of care, even taking on financial risk for spending targets. If the DHA can assist insurers and providers in delivering effective and less costly care remotely and generate savings as they manage the health of populations with serious illnesses or frailty, they may be willing to buy DHA services for their patients. Even then, the insurers, providers, or consumers who would pay for a DHA, and the regulators who protect the public, will first want evidence that digital services can substitute safely for other, more costly services.
Challenges for Policymakers
Fostering effective DHA services also will require new standards governing privacy, security, and “interoperability” of health data. With increasing standardization making it easier than ever for institutions to exchange electronic health data with one another, other data issues have come to the fore. For example, although highly specific, personal digital data from many sources will be the lifeblood of a DHA, the exchange of such information already is posing privacy and security challenges. Currently, use of health records requires consent from an individual. But the authors of health care consent protocols, written decades ago, did not foresee the volume, breadth, or complexity of digital data. Nor did they envision the possibility of automated requests from computer programs acting on a patient’s behalf or other issues related to authenticating identity or data ownership, rights, and responsibilities.
"Under the right conditions, private investors and entrepreneurs will step up to create DHA services."
The public also will require assurances about the integrity of advice from a DHA. Consumer protection implies that the fundamental features of a DHA—the databases, data-exchange protocols, decision-support tools, and treatment recommendations—will have to be tested for accuracy, bias, and conflicts of interest, with periodic monitoring. As they blur boundaries between devices, treatments, and providers, DHA services will challenge traditional regulatory categories that govern professional services and may call for new regulatory approaches. For example, the integrity of the personnel involved in designing and deploying DHA services may need oversight.
Finally, steps may be required to ensure that all patients have a minimum level of access to digital and communication technologies. Otherwise, differences in access to DHA services could contribute to a widening of health disparities.
Overcoming Cultural Gaps
Perhaps the most profound barrier of all, however, is cultural. Technology entrepreneurs, investors, and developers are likely less familiar with the needs of chronically ill patients, the frail elderly, and their caregivers than they are with those of the health-and-fitness enthusiasts who’ve been early adopters of many digital health tools. Similarly, consumer-oriented digital companies also may be perplexed by the demands of health care regulators, like the Food and Drug Administration, or the conditions of participation set by providers that bill Medicare, Medicaid, or other payers.
For their part, health care providers still strive to deliver care that is truly responsive to patients’ needs. If entrepreneurs, providers, and consumer advocates can successfully partner to design DHA services that health professionals want to use, the quest to provide patients with unhindered access to timely care will receive a major boost.
The Role of Philanthropy in Promoting the Vision for a Digital Health Advisor
As a philanthropy working to improve health care for all, The Commonwealth Fund is seeking opportunities to address these challenges and advance the development of a digital health advisor. Under the right conditions, private investors and entrepreneurs will step up to create DHA services. We believe philanthropy can make a difference in several ways:
- By serving as a neutral convener of disparate stakeholders to bridge cultural gaps through education and dialogue.
- By recommending policies that protect consumers while enabling investors, entrepreneurs, providers, and the public to create and offer DHA services.
- By producing evidence about the effectiveness of proposed DHA services through rigorous evaluations of their benefits and risks.
- By identifying the needs of those with the most to gain from DHA services—people with multiple chronic illnesses, frail elders, and people made vulnerable by functional limitations, disability, or low income.
In the near future, we’ll be exploring policy changes that could accelerate development of DHA services. And we’ll be studying the particular needs of populations that could be served by a DHA prototype. The ultimate goal is to clear several paths to the development of trustworthy, high-quality DHA services that help people who seek better health.