Digital health companies (DHCs) and their solutions continue to grow at a rapid pace. This is in part being fueled by the record funding for DHCs, with over $29 billion for US-based companies in 2021 alone. As a result, patients are inundated with solutions from every direction – from employers, health plans, and directly through consumer-oriented apps and wearables. Physicians are also getting into the mix by directly prescribing digital therapeutics. On the surface, the blossoming of the digital ecosystem is a tremendous step forward in the use of technology to address gaps in traditional healthcare. However, “an app for everything” mentality has significant downsides, namely a complex and disjointed patient experience – and arguably, does not result in better quality of care. An integrated, systems and requirements-driven digital approach will put the whole patient back at the center of the digital ecosystem.
The Problem: Volume (Still) ≠ Value
Just as more healthcare spending does not result in better outcomes, having more digital solutions does not necessarily lead to better care. This line of reasoning can be extended to better patient experience and higher value. Not surprisingly, reproducing the fragmentation that exists in the physical world in the digital one leads to suboptimal results. There are four reasons why: 1) increased complexity, 2) redundancy of capabilities, 3) lack of integration, and 4) additive costs.
With at least 1 in 4 Americans having multiple chronic conditions (not including obesity!), it’s not surprising that patients are presented with numerous digital health options. However, just as patients find it difficult to see multiple specialists and understand how all their recommendations fit together, so too can it be daunting to understand how multiple, self-serve solutions work together within the larger context of a person’s whole health (complexity). To make matters worse, there’s no primary care physician in the digital loop to prioritize and coordinate recommendations and workflows (integration). And while there isn’t enough coordination, there is a surplus of features and services such as messaging, coaching, and navigation that are overlapping (redundancy). Yet, these solutions rarely communicate with each other, leading to further complexity. Lastly, while payers, employers, and health systems are likely to bear the financial burden of redundant solutions (additive costs), patients ultimately pay with time, effort, and frustration.
Gaps in Current Response
The response to the challenges above has taken two primary forms: aggregation and conglomeratization. In the former, companies take a curation approach and select a portfolio of “best in class” point solutions to present payers and employers with a menu of choices that are made available to members/employees. This approach solves problems at the enterprise customer level (e.g., vendor fatigue and solution identification), but does not solve problems at the patient level. Since solutions are stacked on top of each other without regard to how well they work together, patient experience suffers. In addition, these stacked solutions create blind spots in data – key patient insights get lost within a fragmented system.
The alternate approach is for a single company to provide the digital experience for a range of conditions and settings. This approach mitigates issues of integration and potential redundancy but poses serious challenges to enterprise customers who must decide how to handle their existing digital assets/relationships and whether a single company can truly provide a comprehensive solution. In practice, this approach can take the shape of a “one-size fits all” solution, which may not account for the needs of specific populations or take advantage of integrating effective third-party solutions.
A Way Forward
The path forward requires a systems-based, patient-centric, and requirements-driven approach. An aviation analogy can help illustrate the importance of these concepts: technology integrators like Boeing and Airbus must understand the requirements/needs of their customers (airlines) and their end-users (the public). These companies do not build an airplane based on the vast number of component technologies available; instead, they integrate the technologies/capabilities to create a system that meets the needs of their customers and end-users. By bringing together the core components of the system they own with other best-in-breed components, integrators are able to extract maximum value from them by seamlessly fusing them together into a final system (i.e., the aircraft). The end result is a solution that is far more valuable and useful than its constituent parts. As I shared in a JAMA article a decade ago, the need for systems integration in healthcare is still desperately needed.
To be requirements-driven in healthcare means understanding the needs of the customer, and most importantly, the patient. All too often, solutions are designed without the needs of end-users in mind. As a real-world example, in our recently published Nature Digital Medicine study conducted at Johns Hopkins that examined popular digital solutions in oncology, we found that the vast majority did not meet the basic requirements of patients, caregivers, or their clinical team. For anyone who has worked in healthcare, there is no great mystery as to what the major stakeholders in healthcare want: customers (payers, employers, health systems) want to provide their members with high-value care that reduces their overall healthcare costs, and patients want high-quality care that is accessible and affordable. The challenge then becomes figuring out what a digital ecosystem that delivers these requirements looks like. As is frequently the case in healthcare implementation, a combination of structure and flexibility is needed.
In practice, this means building a solution with a core set of digital health capabilities that is also modular enough to integrate third-party solutions into a unified and personalized patient and customer experience. It means creating the Boeing or Airbus of healthcare. The corresponding output is a flexible system designed to deliver on the key customer and patient requirements of improved clinical outcomes, greater financial savings, and a positive patient experience. To effectively achieve this, a digital solution must improve the quality of care in an end-to-end fashion across all phases of care: prevention, diagnosis, treatment, and care management. This comprehensive approach is necessary, since improving healthcare quality at every phase drives better outcomes and downstream savings. Too often, point solutions tackle only the fragmentation within their specific clinical area or phase of care, which intrinsically limits the synergies that are possible when considering the health trajectory of the whole individual.
For example, we know the majority of healthcare spending comes from hospital care and clinical service, but utilization in these areas can be a lagging indicator of health. As a result, a complete digital solution must facilitate healthcare’s shift from a reactive to a proactive stance. This can be accomplished by taking ownership of all phases of care and integrating them into a single, longitudinal health journey with an optimal trajectory designed for each patient. In addition, an integrated solution must address several key multipliers that impact clinical and financial outcomes: social determinants of health, mental/behavioral health, and medications. These components have a disproportionate impact across all phases of care and must be part of a comprehensive solution to have maximum impact.
The future of digital health remains bright. However, its success should not be measured in volume of companies, solutions, or funding. Instead, the real measures of success are clinical and financial outcomes and experience. While individual point solutions can make some of these claims, they largely do not consider the whole patient across all phases of care. The current consolidation approaches of aggregation and conglomeratization lack either sufficient structure and/or flexibility to be maximally effective. As a result, a systems-based approach that is patient-centric is needed. The question remains: who will be the systems integrator of healthcare technology and services?
About Simon C. Mathews, MD
Simon C. Mathews, MD is the Chief Medical Officer at Pager, a leading virtual care, navigation, and collaboration platform. He previously served as Chief Medical Officer at Vivante Health and Head of Clinical Innovation at Johns Hopkins Medicine Armstrong Institute of Patient Safety and Quality. Dr. Mathews is an experienced health technology leader and physician researcher with a strong focus on validating and applying technology to address gaps in care delivery. He completed medical school, internal medicine residency, and gastroenterology fellowship at Johns Hopkins, where he remains on faculty as Assistant Professor of Medicine and practicing gastroenterologist.