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J Ambulatory Care Manage Vol. 38, No. 1, pp. 91–94 C 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

A Beginner’s Guide to Digital Health for Ambulatory Care Clinicians Patricia Salber, MD, MBA; Alisa Niksch, MD

Abstract: Digital health technology is already playing a larger role in how healthcare consumers receive information about health concerns and how patients manage wellness and disease. The influence of mobile apps, wireless medical devices and other tools for patient monitoring will soon be felt in almost every physician practice. In an environment where regulatory standards are still in flux, some of these technologies are validated and reliable, others are not. We present the first in a series of systematic guidelines to assist physicians in navigating digital health technologies that they will encounter in the office setting. Key words: digital health, mobile health, remote patient monitoring, healthcare apps, medical device

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HE DIGITAL health movement is here. Whether it is a new wearable for fitness, a wireless infant monitor, or a direct-toconsumer genetic testing platform, physicians are being confronted with myriad new and many times unfamiliar technologies. While the evolution of mobile medical technology innovation has been exhilarating, the effort required by physicians to vet and integrate these tools into their practice has been vastly underestimated. Doctors are looking for resources to reassure them that digital health technologies their patients use are safe and effective. However, they may throw their hands

Author Affiliation: Health Tech Hatch, Larkspur, California (Dr Salber); and Tufts Medical Center in Boston, Massachusetts (Dr Niksch). Dr Salber is the host of The Doctor Weighs In and serves as an advisor to digital health startups, including CliniOps, mHealth Solutions (product is CareSmarts), and DoctorBase. Dr Niksch serves as an advisor to startup companies Sproutling and Genetesis and has conducted research with Zephyr Technologies (now subsidiary of Covidien). Correspondence: Patricia Salber, MD, MBA, Health Tech Hatch, 21 Marina Vista Ave, Larkspur, CA 94939 ([email protected]). DOI: 10.1097/JAC.0000000000000067

up in frustration as the information they need is scattered and often incomplete. In an effort to support physician engagement in digital health, we offer these steps as a Beginner’s Guide. 1. Assess whether your patients are already using medical apps, wireless health devices, or other digital health tools. An IHS Electronics & Media white paper from 2013 forecasted that shipments of fitness wearables will exceed 250 million over the next 5 years. It also predicted that the number of patients using technology to transmit physiologic data to clinicians would exceed 2 million by 2018 (IHS Electronics & Media, 2013). While the use of digital health tools promises to accelerate in the future, there are already numerous patients counting their steps or assessing their sleep quality with various monitoring devices. Many also have electronic scales to measure their weight and apps to track food intake and estimated calorie consumption. According to a comprehensive study from IMS Technologies (2013), there are more than 43 000 healthrelated apps available that can be used to track or inform users about many different healthrelated topics. The value of many of these 91

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apps varies widely, including anything from fertility trackers to inflammatory bowel disease symptom trackers to smoking cessation motivational programs, just to name a few. Your patients may also be using other types of digital devices, such as glucometers (even if they are not diabetic), electronic blood pressure cuffs, smartphone electrocardiographic (ECG) devices, and more. Furthermore, they may be participating in online interactive programs, such as The UnitedHealth Group’s or Omada Health’s diabetes prevention programs (www.omadahealth.com) or the Crohn’s and Colitis Foundation’s “I’ll be Determined” program (http://www. ibdetermined.org/). As in all things related to health and health care, some of these devices and programs are excellent adjuncts to traditional medical care and others are not. The best way to ensure that your patients are using reputable apps is to ask them what apps and devices they are using as a part of routine history taking. If possible, have them show you these apps on their phone. 2. Know what kinds of information your patients are getting from digital health technologies and how they are using it. Many digital health tools are simply educational in nature, and patients will be introducing this information as “something I saw online.” This may stimulate a productive discussion about the unique health challenges your patient faces, either by affirming or refuting certain aspects of the resource. It is important to understand that most patients will be seeking health information outside of your office, and it is up to you to negotiate this increasingly complex relationship with an empowered patient. In fact, a recent survey showed that although 90% of patients want to use online resources to manage their health, including seeking health information, 85% still want face time with their doctors (ACHPS, 2012). Asking about digital health tool use and reviewing any captured data present an opportunity not only to help patients find and use the best tools for information, self-management, and tracking but also to reinforce the message that you view

self-management as an important part of their overall care plan. A slightly different approach would need to be taken with mobile and wireless medical devices that provide specific biometric data to patients. These devices could be anything from a wireless blood pressure cuff, digital glucose monitors, mobile ECG monitors, or infant monitors that communicate with a parent’s smartphone. Patients using these tools are searching for ways to monitor their own (or their family’s health) and make informed decisions based on the data they gather. The willingness to share their experience with their physician is an implicit invitation to involve them in managing the use of the technology and guiding their response to the data. Some of the data communicated will require your close monitoring and verification. The take-home message is not to be threatened—have fun educating yourself on these new technologies, and develop better relationships with your patients in the process. 3. Understand if the app, device, or program is safe and provides accurate information. To date, very few digital health tools have been studied formally with results published in peer-reviewed literature. There are some notable exceptions, including the WellDoc app (Quinn et al., 2008, 2011), CareSmart text messaging for diabetes care (Nundy et al., 2014), and Omada Health’s diabetes prevention program (Sepah et al., 2014). Some devices have obtained Food and Drug Administration approval, including the AliveCor and ECG Check ECG monitors, Propeller Health’s asthma management sensor platform, the WellDoc diabetes app, and the Proteus Digital Health ingestible pill sensor. If the tool has not been studied formally, there are a few things you can do to get a sense of the app’s integrity. One is to look it up on iMedical Apps (http://www.imedicalapps. com), a Web site where physicians post reviews of many different apps and tools. The other is to go to the app developer’s Web site and see if there are any physicians or other clinicians involved in product development.

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A Beginner’s Guide to Digital Health 4. Try out the app or device yourself. Take the time to explore digital health tools relevant to your practice. Many are free to download, but some of the devices can be pricey (the AliveCor ECG monitor is $199, and the ECG Check device is $129), for example. When testing out an app, look for a few things: Is the medical information provided evidence-based or best practice? Is the device user-friendly? Does the device make it easy to transmit data to the treating physician? If so, is there an ability to customize the type and timing of the transmission? Aside from this, some important factors to consider are how truly “mobile” these digital health tools are— is it a device that is cumbersome in some way or that is too easily forgettable to use in a busy schedule? Does the device work only for people who see, hear, read, and type perfectly? This may rule out some of your elderly and disabled patients and probably most in need of mobile health surveillance. In most cases, adherence to mobile health tools is negatively influenced by how many demands the technology places on the patient. Don’t ask your patients to use a technology that you have no motivation to use yourself. It is worth spending the time to get to know a few apps in each treatment area in which you commonly see patients. You will soon have a list of helpful digital health tools that you can recommend to your patients. 5. Assess whether you and your patient see the app or device as a way to improve your communication and support the doctor-patient relationship. Patients still value their communication with their physicians. Any impedance to this communication is incredibly frustrating, and there is more and more demand for rapid, if not instantaneous, turnaround times for feedback in response to patient questions and concerns. The use of digital health technologies, especially those that facilitate remote patient monitoring, may improve your insight into the day-to-day status of your patients and in a much more efficient manner through electronic communication. In the same way, a technology that gives real-time data to your patients can establish a point of reference for

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the current status of their health condition. Longitudinal usage of this type of platform can track deviations from that baseline (ie, for blood pressure, blood glucose, etc) and enable physicians to make appropriate interventions, often far in advance of their next in-office follow-up visit. It is worth noting, however, that a fairly small minority of apps have capabilities of reminding or alerting patients, and even fewer can communicate data to other parties. However, information seamlessly communicated through an SMS message or secure electronic portal may not only improve work flow, but can solidify the relationship with patients. When recommending or supporting the use of a digital health app or device, it is important to know what kind of data will be available to the patient and subsequently communicated to the clinician. The knowledge that a physician is reviewing and responding to personal health data should be a reassurance to patients and their caregivers. It is important to understand that there may be initial anxiety using the technology and gaining information previously unknown, reassurance comes when appropriate intervention and counseling constructively respond to the shared data. The benefits from 2-way communication as mediated by a digital health tool should only reinforce a positive feedback loop and promote improved compliance with prescribed treatments. 6. Determine if the app fits into your clinical work flow. This can be admittedly a difficult problem for many clinicians. Everything starts with one patient using one type of digital health tool, and inevitably this changes the paradigm upon which your medical practice is run. The technology may be so compelling that you may decide that this is a useful addition to your arsenal of patient monitoring tools. The benefit to patients may significantly outweigh any inconvenience or extra investment to you or your staff. This will be up to you to judge and implement as appropriate. However, there are situations when patients will be using very unique apps that do not extend to a broader patient population.

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How you deal with this will likely be on a case-by-case basis—many of these tools may apply to diagnoses that do not require day-today surveillance. An example of this could be an app that provides a food diary or weight loss tracker or even an app to remind patients to drink more water. A digital health tool may not initially integrate into the electronic health record. Electronic health record access is extremely restricted in general, so this should not be an initial expectation when dealing with new innovations. Although this may be an important criterion for you as a clinician, this priority is likely not shared by the typical health

care consumer, who will be increasingly confronting his or her physicians with innovative digital health tools. The process of integrating the world of digital health into your practice can be a daunting task. We want these steps to help you discover some amazing tools to improve the communication and management you provide to your patients. Patients will be presenting you with new technology that will require some research to ensure that these tools are reliable and safe. While this does take some effort, we hope this guide helps you enjoy this adventure. Stay tuned for more information and insight on digital health in future issues.

REFERENCES ACHPS. (2012). The Accenture Connected Health Pulse Survey, 2012. Retrieved from http://www .accenture.com/SiteCollectionDocuments/PDF/ Accenture-Is-Healthcare-Self-Service-Online-Enoughto-Satisfy-Patients.pdf IHS Electronics & Media. (2013, September). Wearable Technology—Market assessment; An IHS whitepaper. Englewood, CO: Author. IMS Technologies. (2013, October). Patient apps for improved healthcare, from novelty to mainstream. Danbury, CT: IMS Institute for Healthcare Informatics. Nundy, S., Dick, J. J., Chou, C. H, Nocon, R. S., Chin, M. H., & Peek, M. E. (2014). Mobile phone diabetes project led to improved glycemic control and net savings for Chicago Plan Participants. Health Affairs, 33(2), 265–272.

Quinn, C. C, Clough, S. S., Minor, J. M., Lender, D, Okafor, M. C., & Gruber-Baldini, A. (2008). WellDocTM mobile diabetes management randomized controlled trial: Change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technology & Therapeutics, 10(3), 160–168. Quinn, C. C., Shardell, M. D., Terrin, M. L., Barr, E. A., Ballew, S. H., & Gruber-Baldini, A. L. (2011). Randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care, 34(9), 1934–9142. Advance online publication. doi:10.2337/dc11-0366 Sepah, S. C., Jiang, L., & Peters, A. L. (2014). Translating the diabetes prevention program into an online social network: Validation against CDC Standards. The Diabetes Educator, 40(4), 435-443. Advance online publication.

Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

A beginner's guide to digital health for ambulatory care clinicians.

Digital health technology is already playing a larger role in how healthcare consumers receive information about health concerns and how patients mana...
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