An app a day shouldn't keep the doctor away
Engaging physicians is critical to deploy digital healthcare solutions that really empower patients
As we enter the third wave of digital health, it’s time to learn from earlier experiences and promote adoption of new applications by putting doctors front and center. The route to empowering patients should go right through their physicians, not around them.
The doctor has been central to patient health for as long as a figure recognizable as such has existed – since at least the Ancient Egypt of 5000 years ago. The first doctor mentioned by name, Hesy-Ra, was known as the “Chief of Dentists and Physicians” and was responsible for the health of the pharaoh Djoser during the 27th century BC.
And while the likes of Hesy-Ra probably had more in common with priests or magicians than with a modern medic, the centrality of the patient-doctor relationship has remained in place until the present day. For centuries, this relationship had a decidedly paternalistic bent: the physician took decisions, the “good patient” obeyed. Times may have changed since then, but even the fairly recent concept of patient-centered medicine places the patient-doctor relationship at its heart.
Digital health attempted to break this paradigm. The first iterations of digital health shifted attention from the doctor, aiming applications and devices directly at the patient (or as the developers would have it, the consumer). Only 20% of the health-related applications downloaded in 2018 had input or advice from medical professionals during their development, according to a University College London study. Applications focused on slick interfaces for consumers, not on the functionality that would enable doctors to use their insights in their diagnostic and monitoring process.
That developers targeted their wares directly at consumers is unsurprising: it follows the tech “logic” of disruption by cutting out intermediaries wherever possible. The more sacred the cow to be killed, the more disruptive, and therefore, the better. Why shouldn’t the philosophy that made Amazon, Airbnb and Uber such success stories work for health? After all, as Jeff Bezos said, “Even well-meaning gatekeepers slow innovation”. And anyway, it seemed to be the next logical step for the patient, empowered by the internet with access to information previously only available to doctors.
It has not proven to be a very good strategy for healthcare, though. The health ecosystem is considerably more intricate than that of, say, retail. Digital health products need to appeal not just to consumers, but to a complicated landscape of stakeholders (doctors, patients, insurers, regulators) all whom have a say in whether a new technology is adopted. The doctor, as the centerpiece of the system for centuries, has one of its strongest voices.
The family doctor doesn’t just provide a route to market or a physical asset, but years or decades of specialist education and experience. The decisions that a patient needs to take tend to be infinitely more complex than those required on more common peer to peer platforms. At stake is not an ill-fitting pair of shoes or a holiday cottage that doesn’t quite live up to expectations, but human lives.
And the value added by the physician is not just the access they provide to knowledge or medication: it is the relationship itself. As a 2002 academic article put it, “The importance of an intimate relationship between patient and physician can never be overstated, because in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship”. In the case of chronic diseases, which require ongoing monitoring and behavior change rather than a one-off intervention, this is particularly pertinent.
An example is the perennial problem of patient adherence. As many as 40% of patients fail to adhere to treatment recommendations, seriously jeopardizing their ability to control or overcome their disease. But adherence rates have been found to be nearly three times higher in primary care relationships characterized by very high levels of trust, coupled with physicians' knowledge of the patient as a whole person.
Faced with a plethora of applications that didn’t integrate with their systems or give them the information they needed, doctors were understandably more reluctant to throw themselves into the new digital landscape than their patients. The outcome was that few of the trumpeted benefits to patient care were achieved.
And it seems that the tech disrupters have realized this. A 2017 study by Rock Health discovered that over 60% of digital health companies that started as business-to-consumer (B2C) endeavors subsequently moved to a business-to-business (B2B) or business-to-business-to-consumer (B2B2C) model. It is now commonly accepted that B2C does not work in healthcare. Almost 80% of venture funding for healthcare goes to B2B or B2B2C models, with equity tickets that are 30% higher on average.
If the patient-doctor relationship is front and center in healthcare across the world, it is arguably even more so in Latin America. Health systems on this continent are characterized by a particularly high level of fragmentation, between state, health insurance and private clinics, and segmentation between different institutions – trade unions, insurers, payers, myriad hospitals and specialist clinics, and so on. Doctors may have contracts with 20 or more of these, working as an independent contractor rather than an employee. Thus the relationship of the patient is, first and foremost, with their doctor. And because of the complex web of players involved, the doctor’s opinion takes priority over what may be numerous different protocols.
At the advent of the so-called third wave of digital health, we are starting to see disease-specific apps that provide medical and even therapeutic value come to market. A far cry from prior endeavors, these tools and services are highly complex, very expensive and need to be integrated with other sources of information to be most useful. The barriers to acquisition and use for a patient – such as research into different products, understanding of the right product given their condition and particularities, correct usage, using the information produced to make decisions - are enormous.
If third wave digital applications are going to live up to their promise, this time around it cannot be left to the patient to drive adoption. The doctor, with their unique role, skillset and position in the ecosystem, will need to take center-stage. It is the doctor who will be able to recommend the most appropriate digital solution, based on a profound understanding of the patient’s condition and situation. The doctor will be able to advise on and monitor the correct usage of the application; to promote motivation and adherence; and, by integrating data produced with their own information, be able to understand, draw conclusions and make decisions that will enable them to provide better patient care.
The medical profession has, perhaps unfairly, gained a reputation for uneasiness around technological innovation. In fact, medical interest in digital health seems to be growing. A recent American Medical Association (AMA) study found that 87% of physicians believe that digital health will offer some or a definite advantage to the care that they are able to provide for their patients. And this interest is translating into action. The 2020 IPSOS Digital Doctor report estimates that, worldwide, 46% of doctors have recommended some form of digital health solution to their patients, although this percentage varies wildly across the globe, with China by far the biggest adopter to date.
But critically, doctors want to take a key role in what digital health solutions they use and how they will be implemented. In the AMA study, 42% of respondents said they would want to be responsible for the future implementation of digital health solutions and 47% at least consulted. One of the drivers of perceived resistance to technological change on the part of the medical profession appears to be the tendency by program managers to prioritize whizzy technology over understanding of physician needs and workflow. A survey carried out by Bain and HBR in 2017 found that doctors do not generally feel involved in key decisions around adoption of new models, which as everyone who has been involved at either end of a change program will know, is a key cause for resistance.
This may be the time to learn from past mistakes and put doctors not only in the center of digital health utilization, but in the center of its implementation. As Toby Cosgrove, heart surgeon and ex-CEO of the Cleveland Clinic, put it in a recent Harvard Business Review article: “Doctors… must be central players in [healthcare] transformation. Any ambitious strategy that they do not embrace is doomed”.
Copyright 2020 Axenya Holdings Inc.