In the city of New York and right across the UK, nurses are striking due to poor working conditions and pay. Digital therapeutics could be a shot in the arm for overstretched and underfunded health services. But, for digital therapeutics to succeed in alleviating and modernizing healthcare, clinical and technology leadership need to adopt the same approach to digital methods and change as they did during the COVID-19 pandemic.
Digital therapeutics use technology as part of a treatment course through either management, prevention or treatment of a health condition. As a result, there is a broad range of digital therapeutics, from simple apps that nudge behaviour and devices for collecting and reporting conditions through to the use of gamification and artificial intelligence (AI) for diagnosis.
Typically digital therapeutics are used to help patients adopt healthy behaviours as part of their treatment; this can range from reminders to take medications, to active living. For the healthcare sector, digital therapeutics have the ability to overcome the major constraints of clinical time and number of beds.
The breadth of digital therapeutics is perhaps why the decade-old technology is still struggling to become a mainstream form of treatment. Tim Andrews, Chief Operating Officer and co-founder of ORCHA, a business that provides a health app library, says:
I don’t use the term digital therapeutics as it has become synonymous with complex technology like diagnostics. This leads to non-complex uses being ignored.
Quite simple patient facing digital health interventions can do a really effective job in areas like smoking cessation, weight loss, stress and anxiety management; and even with long-term conditions like COPD (Chronic Obstructive Pulmonary Disease), diabetes and hypertension.
ORCHA operates a library of health Apps and works with the likes of Public Health England, the Mental Health Commission of Canada and the American Telemedicine Association. Sleepio, an App developed by Big Health and a member of the ORCHA library, uses cognitive behavioural therapy (CBT) to treat insomnia, and Andrews says the App has been successful and is less costly to healthcare providers than sleeping pills.
As healthcare costs increase, digital therapeutics have been cited as a way to reduce costs and increase outcomes. Andrews says:
If you are awaiting surgery, then a digital product that helps you stop smoking or reduce weight by being more active will make a massive difference to how you engage with surgery, and how well the surgery goes and your recovery from it.
The knock-on effect for the health service is phenomenal because we know that the healthier you are going into surgery, the better the outcomes, the shorter the length of stay, and there are less readmissions.
An example of this is the National Diabetes Prevention Programme, operated by Ingeus, a company that delivers a number of UK government-funded programmes from health to probation. Working with the Lancashire and South Cumbria Health and Care Partnership, digital therapeutics were used to ensure diabetes patients managed their nutrition, exercise and weight loss.
Availability of beds and readmissions are two of the most costly pressure points on the healthcare system. In the USA, connected blood pressure, glucose, and weight measurement devices are cutting hospital readmissions. This benefits not only the care provider but the patient too. Research by ORCHA finds that the average outpatient appointment costs £36 in time and travel costs.
Digital therapeutics can reduce the number of in-person outpatient appointments needed, which was seen during the pandemic. Everything from bone fracture clinics to digitizing paper diaries that are used for gestational diabetes mellitus (GDM) treatment can be done virtually using the likes of the GDm-Health App.
Back in 2019, the Topol Review carried out for the UK government highlighted how digital therapeutics, as well as wider adoption of technology, was necessary for healthcare. The Topol Review stated:
The NHS has been working towards a less paternalistic relationship between patients and staff for some time. Digital healthcare technologies have the potential to speed up that process, to empower individuals to be more informed about their care, and to allow them to work together with healthcare staff to make treatment decisions.
Redesigning care - digitally
And yet, in 2023, the NHS is beset with nationwide strikes and ambulances stuck outside accident and emergency (A&E) wards. Andrews says:
The time has never been more right, and we are writing to Steve Barclay (Conservative Party Secretary of State for Health and Social Care) to point out that he could save millions of GP appointments, save A&E admissions, ambulance journeys and unplanned admissions.
The adoption of digital therapeutics requires a rethink of the care process. Rachel Dunscombe, former Director of Digital at the Northern Care Alliance NHS Group in Manchester, says care pathways need to be designed with a strong digital element. She says:
With the workforce shortage, digital therapeutics is about how you augment human capacity and how you augment medication.
The Topol Review came to a similar conclusion. It said:
The current workforce delivering care will need to know for whom, where, when and how digital technologies are able to improve the care pathway and health outcomes…Digital medicine is already changing the way people interact with healthcare.
Ian Cohen, Chief Product & Information Officer at Acacium Group, a provider of healthcare and social care staffing, managed services, and digital therapeutics, says:
There are so many processes in the pre-clinical and clinical flows that can be digitized with these technologies; this helps the patient and will benefit the healthcare provider.
He adds that precious resources are used in the build-up to an operation, and cancellations are costly, but digital processes ranging from basic tele-medicine / tele-consult through to elements of digital therapeutics can help prevent this and improve the experience for both parties.
Barriers to change
So if digital therapeutics is 10 years old, why is it not transforming healthcare? According to Andrews, it is the inability to make time for change. Which leads to a return to old processes of governance. He says:
When we speak to people managing elective care, they are generally receptive to digital, but what they haven’t got time for is to take the adoption through the governance process as they are too busy trying to find beds for patients.
Although the pandemic swept away barriers to change and decision-making, the PPE procurement scandal involving the governing Conservative Party in the UK and Michelle Mone has put a brake on streamlined processes. In addition, digital therapeutics and digital healthcare have yet to find their place within the structure of a typical healthcare provider, according to Andrews:
Digital health gets bundled up with the Electronic Patient Record (EPR), Patient Administration System (PAS) and even imaging. The implementation of an EPIC EPR and a smoking cessation App are treated in the same way, yet they couldn’t be further apart. The priority of healthcare CIOs is to put in an EPR and improve the connectivity of the infrastructure. All good solid stuff, and as a result, they cannot prioritize digital health interventions.
He adds that Clinical CIOs (CCIO), which were introduced in the UK, Ireland and the USA from 2016 onwards, have, like their CIO peers, become consumed by these major EPR implementations. The Topol Review and Dunscombe also highlight that the high levels of risk aversion, especially towards data and ethics, are potentially holding digital therapeutics back. Dunscombe says:
Ethics is huge, and any medical intervention has to go through some form of governance to make sure it is fit for purpose.
The CIO’s role
Although digital therapeutics is a medical intervention and, therefore, primarily the responsibility of clinical leadership within a healthcare provider, the technology will rely on the data, network and security infrastructure a CIO provides. Healthcare IT and the CIO will move away from operating technology to orchestrating change; then, the CIO will become focused on delivering outcomes - in other words, healthy patients.
James Thomas, CTO of Wellcome, a medical research funding body and the former CIO of University College London Hospital (UCLH), says this is not a new situation for CIOs. He adds:
Medical devices, like those used in an operating theatre, are connected devices. There is medical physics, and IT involved.
As to the CIO stepping up and becoming a leader and advocate for digital therapeutics, Thomas says:
The most important things would be getting involved as-soon-as-possible and talking to the medical directors about the apps, the challenges and ensuring you get the conversation going with everyone in the room. There will be long-tail implications.
He adds that it is one thing to stimulate interest in digital therapeutics, but healthcare CIOs will also need to be aware of pressures coming as a result of high interest. Thomas says:
I would also be worried about how digital therapeutics scale. As there will be an absolute tidal wave of demand, and you could soon become the blocker - again!
Cohen at Accacium Group adds that CIOs will also need to think of digital therapeutics in terms of how it integrates and digitizes the management of a healthcare provider. Digital therapeutics will be a front-end or action-based technology that needs to be part of every aspect of healthcare from beds, clinical staff, pharmacy and postoperative care, he says:
We need to think in terms of platforms – not just point applications. The increase in mission and remission-type solutions are fine, but their scope is often limited, and they inevitably need to connect to other services for patient data (records) or punch in/out to human activities flow (tests etc). So, we need to think in “platform terms” with that ability to connect and enable every part of the outcome digitally.
Healthcare and its technology and clinical leaders will need to understand and embrace digital therapeutics. Firstly, in the current situation, any lever that makes care healthier and more effective has to be pulled upon. Secondly, the next generation of digital natives is already using digital therapeutics on a simple level, measuring their exercise, ovulation, and diets and caring for their mental well-being via digital means. If the healthcare sector doesn’t reflect this change in lifestyle, then it will be disintermediated. In the case of publicly funded healthcare providers, this will put its funding in a politically volatile place.
Finally, healthcare cannot exacerbate digital exclusion, especially amongst the poor, old and frail. Digital therapeutics will succeed when matched with digitally savvy patients.