If Digital Health is the Future, the Future is Not Here. Yet.
(Illustration by Teodros Hailye/KQED)
In 1995, in order to educate its clients on what technology to adopt, the IT consulting firm Gartner released a graph illustrating the “hype cycle.”
The model posits that when a new technology is developed, it creates a frenzy of anticipation, leading to a Peak of Inflated Expectations. Failing to live up to its pie-in-the-sky promise, the technology then becomes the butt of jokes and derision — a Trough of Disillusionment.
But as it improves, it reaccumulates credibility -- the Slope of Enlightenment. The technology then matures into the mainstream, where the rollercoaster lifecycle finally smooths out along the Plateau of Productivity.
And this, says Dr. Robert Wachter, author of "The Digital Doctor" and chair of the Department of Medicine at UCSF, “turns out to be a perfect map for digital medicine.”
Does This Stuff Work?
A meta-analysis published this month in the journal Digital Medicine would seem to buttress Wachter’s view. The study, conducted mostly by researchers at Cedars-Sinai Medical Center in Los Angeles, takes a broad look at the effectiveness of wearable sensors. The study looked at 16 randomized controlled trials, published from 2000 to 2016, which researchers assessed to be high quality. To be included in the study, devices had to be non-invasive, wearable, and capable of automatically transmitting data to a web portal or mobile app for review by patients or health providers. Among the devices tested were internet-connected weight scales, blood pressure monitors and activity trackers with text-message reminders.
The primary question researchers wanted to answer: Do these wearable biosensors make patients healthier?
Not very much, was the conclusion. The analysis found no significant difference in health outcomes like weight or blood pressure between patients who used the devices and those who didn't.
The researchers say they were not surprised, and they hope the work will pave the way for better development and use of remote health monitoring.
“We’re trying to emphasize this is not the end of wearables,” says co-author Dr. Brennan Spiegel, director of Cedars-Sinai Health Services Research in Los Angeles. “[But] we don’t want to overpromise what these can achieve.”
The authors did note some positive effect in certain cases. For instance, a study looking at Parkinson’s patients found a positive effect when physical therapy included devices that gave feedback about gaits; and in some trials patients did lose weight.
“The most successful studies tend to be coupled with some behavioral intervention,” Spiegel says. This added component sometimes took the form of a health coach or cognitive behavioral therapy, in addition to use of the device.
That means the greatest hurdles to efficacy in the digital health revolution may not be technical, but human.
“What we conclude in the study is that digital health is not a computer science or an engineering science; it’s a social and behavioral science."
Other recently published research, a systematic review of systematic reviews, focused on mobile health interventions, most frequently involving text messaging. The analysis, published in the Journal of Medical Internet Research mHealth and uHealth, looked at 371 studies published between 2009 and 2016, comprised of nearly 80,000 patients. The studied interventions included apps to manage chronic disease, increase treatment adherence and modify behavior. The analysis found evidence that mobile health apps helped with a variety of conditions, including symptom improvement in chronic pulmonary disease and heart failure; glycemic control in diabetes patients; and blood pressure in those with hypertension. There was also evidence that text reminders improved adherence to tuberculosis and HIV therapies.
However, the quality of the evidence for many studies was rated as generally low. Among the more rigorous studies were those that found good evidence for improvement in asthma symptoms, appointment attendance and smoking cessation rates.
Medicine Needs to do Better. Will Technology Help?
Wachter ticked off the ways medicine is "coming up short in what we want from it."
"Safety is not very good," he says. "We harm and kill a lot of people because of medical mistakes. People are not very satisfied ... . Access is often quite bad. And the costs are bankrupting local governments, national governments, and businesses and individuals.”
And yet, “Medicine is probably the last field to be touched by technology," he says. "Think about how manufacturing, retail, financial services, travel, journalism, pretty much every field has been overtaken by technology.”
These manifold inefficiencies present a natural target for technologists, Wachter says.
“You have the technology trigger, a massive uptick in expectation. Then, of course, studies like [the one in Digital Medicine] come out and it leads to a rapid downslope, that Trough of Disillusionment."
Still, Wachter, as well as many other experts, believe remote sensors, mobile health and tech-enhanced medical services will play an important role in the future of medicine, because there are so many people who need help monitoring chronic disease and guidance on diet and exercise. It’s just too time-consuming and costly to always get these directly from medical professionals, Wachter says.
“Right now many people take a half-day off work to go to a 15- minute visit to see the doctor. That’s crazy. How can that be the model over time?”
Wachter predicts digital health devices will eventually become as indispensable as smartphones and personal assistants.
“That has not happened yet in remote patient monitoring. My suspicion is that over time it probably will, but we have to learn a lot.”
Melissa Buckley is director of the Health Innovation Fund for the California Health Care Foundation, which is dedicated to improving health care for low-income state residents. The fund invests in technology and service companies it hopes will help in that mission.
Buckley says she’s seen companies only in the last two years try to shorten the hype cycle, which they're doing by becoming more realistic and intentional in the design and deployment of technology. She points out that some of the studies cited in the Digital Health analysis date back to 2000, when devices were relatively primitive.
During the initial phase of excitement over using technology to solve health problems, she says, many investors put money into simple concepts. “They wanted a quick win, but now they realize there aren’t a lot of quick wins in health care.”
The field is learning, she believes, to be more attuned to what patients really need.
“But just because [some tool] is digital, we shouldn’t think it will be magically effective.”