Digital health is our past, present and future

Digital health was introduced a long time ago. In 1878 The Lancet published an article about the radio doctor, implementing the telephone in the health care practice to prevent home visits in the United Kingdom. A few decades later there was discussion about the telecardiogram in 1906, for which Willem Einthoven won the Nobel Prize in Medicine in 1924. In the 60’s and 90’s of the last century, respectively, teleradiology and teledermatology were introduced. It was only at the start of the new millennium that digital health took off significantly, mainly due to the development of internet (e-health) and the mobile phone (m-health).

The relatively new terminology of digital health covers the above-mentioned developments. The Healthcare Information and Management Systems Society (HIMSS), an American not-for-profit organisation dedicated to improving health care quality, has launched the often used definition of digital health as: “Digital health connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated, interoperable, and digitally-enabled care environments that strategically leverage digital tools, technologies and services to transform care delivery.”[1]

This definition partly includes the ‘why’ of digital health. Like traditional medicine, digital health focuses on four goals: enhancing patient experience, improving population health, reducing costs, and improving the wellbeing of the health care provider.[2] In addition to these specific targets, it is often the lack of health care providers in low-and middle-income settings that makes digital health solutions even more beneficial here.

The rise of technology and especially the increased usage of mobile phones induced a spectacular growth of digital health. In 2018 close to 5 billion people worldwide used a mobile phone, and almost half of them used a smartphone.[3] Mainly through the mobile phone, in 2017 already more than 325,000 health apps were available, accounting for 3.7 billion downloads worldwide, which is a growth of 700% between 2013 and 2018. However, the quantity of apps and digital healthcare does not necessarily say something about the quality.

There are multiple elements of digital health. Telemedicine is one of the first and still one of the main elements of digital health. This includes: (i) health education via websites with patient information, like the British NHS.uk or the Dutch website Thuisarts.nl,[4] (ii) interventions to measure and manage blood pressure at home,[5] (iii) remote diagnostics and treatment advice through teledermatology,[6] and (iv) online treatment and care of depression.[7]

Other important elements of digital health are the medical devices which range from weighing scales which send measurements to digital platforms[8] to devices to control blood glucose in diabetics,[9] often increasingly linked to artificial intelligence components and electronic health records.

Digital health is rapidly increasing in almost all areas of medicine, like the previously mentioned dermatology, radiology and cardiovascular prevention, with mental health in the lead. The application of mental digital health is partly due to the increased burden of mental health worldwide, combined with the relatively limited number of trained health care workers, and possibly a lower need for direct physical examination compared to other fields of medicine. Both in high- and in low-income countries there is a strong need for digital components to cover mental support and care, and to both literally and figuratively close the distance between the patient and the caregiver.[10] Current digital interventions in mental health cover almost the complete range from prevention and diagnostics of mental health disorders to online standardised and validated questionnaires and apps as well as chatbots and online therapists for treatment and medication.

Digital health however faces barriers and challenges. Electronic devices and a digital network are dependent on the reliability of the electricity supply, network and devices. Next to these technical requirements, the level of digital literacy and privacy issues play a pivotal role as well as the costs involved, from developing to implementing a reliable digital health care intervention system including programming and marketing input. A major challenge of digital health is how to include the most vulnerable and marginalised. Although there is an enormous growth in the usage of digital health, there is a risk that this mostly benefits those who already know how to find their way in the health system. Due to practical and commercial reasons, several digital health interventions are aimed at the so called ‘worried well’, a relatively healthy and wealthy subpopulation who would like to spend large amounts of money and time to continuously optimise their wellbeing although the overall impact on their health is limited.[11] On the other hand, unfortunately there still are specific groups getting less access to digital health interventions than others.[12] The Covid-19 pandemic demonstrated once again the further increase in health care inequality, partly due to the fact that the most marginalised groups, such as the elderly and less educated people, had difficulties in continuing their care online.[13]

There are several inspiring examples of how digital healthcare is functioning already in several LMICs, ranging from a digital health ID in Benin or online pharmacy in Bangladesh to an innovative genetic testing programme in Nigeria and a digital platform to connect with dietitians, nutritionists or health coaches in Egypt.[14] Digital health is our past, present and future. It has been woven into medical practice since the 19th century, is now a much greater part of our daily practice, and will definitely increase the access of present and future generations to more efficient, effective and equitable healthcare.

References

1. HIMSS [Internet]. Chicago: Healthcare Information and Management Systems Society, Inc. (HIMSS); 2021. Snowdon A. Digital health: HIMSS defines digital health for the global healthcare industry; 2020 Mar 2. Available from: https://www.himss.org/news/himss-defines-digital-health-global-healthcare-industry
2. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713.
3. Pew Research Center [Internet]. Washington: Pew Research Center; 2021. Silver L, Smartphone ownershop is growing rapidly around the world, but not always equally; 2019 Feb 5. Available from: https://www.pewresearch.org/global/2019/02/05/smartphone-ownership-is-growing-rapidly-around-the-world-but-not-always-equally/
4. Spoelman WA, Bonten TN, De Waal MW, et al. Effect of an evidence-based website on healthcare usage: an interrupted time-series study. BMJ Open. 2016 Nov 9;6(11):2013166. doi: 10.1136/bmjopen-2016-013166. Erratum in: BMJ Open. 2017 May 4;7(4):e013166 corrı.
5. McManus RJ, Mant J, Franssen M, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018 Mar 10;391 (10124):949-59. doi: 10.1016/S0140-6736(18)30309-X. Epub 2018 Feb 27.
6. Finnane A, Dallest K, Janda M, et al. Teledermatology for the diagnosis and management of skin cancer: a systematic review. JAMA Dermatol. 2017 Mar 1;153(3):319-27. doi: 10.1001/jamadermatol.2016.4361.
7. Arjadi R, Nauta MH, Scholte WF, et al. Internet-based behavioural activation with lay counsellor support versus online minimal psychoeducation without support for treatment of depression: a randomised controlled trial in Indonesia. Lancet Psychiatry. 2018 Sep;5(9):707-16. doi: 10.1016/S2215-0366(18)30223-2. Epub 2018 Jul 11.
8. Rahimi K, Nazarzadeh M, Pinho-Gomes AC, et al. Home monitoring with technology-supported management in chronic heart failure: a randomised trial. Heart. 2020 Oct;106(20):1573-8. doi: 10.1136/heartjnl-2020-316773. Epub 2020 Jun 24.
9. Fagherazzi G, Ravaud P. Digital diabetes: perspectives for diabetes prevention, management and research. Diabetes Metab. 2019 Sep;45(4):322-9. doi: 10.1016/j.diabet.2018.08.012. Epub 2018 Sep 19.
10. Fu Z, Burger H, Arjadi R, et al. Effectiveness of digital psychological interventions for mental health problems in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Psychiatry. 2020 Oct;7(10):851-64. doi: 10.1016/ $2215-0366(20)30256-X. Epub 2020 Aug 28.
11. Morrissey EC, Glynn LG, Casey M, et al. New self-management technologies for the treatment of hypertension: general practitioners’ perspectives. Fam Pract. 2018 May 23;35(3):318-22. doi: 10.1093/fampra/cmx100.
12. Ngaruiya C, Oti S, Van de Vijver S, eta 1. Target women: equity in access to mHealth technology in a non-communicable disease care intervention in Kenya. PLoS One. 2019 Sep 11;14(9):e0220834. doi: 10.1371/journal.pone.0220834.
13. Van Deursen AJ. Digital inequality during a pandemic: quantitative study of differences in COVID-19-related internet uses and outcomes among the general population. J Med Internet Res. 2020 Aug 20;22(8):220073. doi: 10.2196/20073.
14. GSMA [Internet], London: GSM Association; 2021. Health systems, digital health and COVID-19: insights from Bangladesh, Myanmar, Pakistan, Benin, Nigeria and Rwanda; 2021 Jan 26. Available from: https://www.gsma.com/mobilefordevelopment/resources/health-systems-digital-health-and-covid-19/