Digital Health Innovation: Provider And Developer Viewpoints

Health plans and provider organizations are flooded with pitches from digital health companies. Once vetted and purchased, the digital health companies who sold the solution face challenges with integration into clinical care, workflow, and adoption.

RTI Health Advance's director of digital health research and advisory services, Brandon Aylward, PhD, connected with colleagues to solicit three different perspectives to top-of-mind questions on the adoption and use of digital health applications and innovation in the industry. To discuss their answers, or your digital health challenges and goals, contact Brandon through RTI Health Advance.

Provider perspective on digital health tools

S. Trent Rosenbloom, MD MPH, Vice Chair for Faculty Affairs & Professor, Department of Biomedical Informatics; Director, Clinical Effectiveness Research for VHAN.

Vanderbilt University Medical Center is the largest comprehensive research, teaching, and patient care health system in the Mid-South region and based in Nashville, TN.

Trent: What are the biggest challenges digital health must overcome right now?

I think a lot about two big challenges for digital health: patient-engaging technologies and the burden of clinical documentation.

With patient engagement technologies, our patients now have unprecedented access to their electronic health information as a result of the most recent stage of the 21st Century Cures Act's expanded prohibition on information blocking. With the new law, patients can finally realize the 25-year-old promise of easy access to healthcare-related clinical information when, where, and how they want it, if they want it.

However, this new era of data transparency has made other challenges more urgent, including disparities in access to patient portals and other such technologies by diverse groups of patients, a persistent lack of control by patients over what they do and do not want to share with others, poor user interfaces, and overburdened healthcare professionals who are unable to counsel or educate patients about their health data in a timely fashion.

The second challenge that I think about is the worsening burden clinical documentation places on our healthcare professionals. This includes writing clinical notes, orders, prior authorization paperwork, and addressing other administrative documentation needs. Doctors, nurses, and other professionals are dealing with a crisis of burnout and burden, and the seeming administrative tasks that get in the way of healthcare delivery create terrible resentment and dissatisfaction.

Working with several key leaders in the field, we started the 25x5 effort to reduce the burden of clinical documentation to 25% within five years. This effort targets the design of relevant digital technologies by identifying exemplars of best practices, though does not stop there. The effort additionally seeks to address policy, knowledge, and regulations that drive documentation burden.

Trent: What advice do you have for fellow clinicians and healthcare leaders in evaluating digital health tools?

Right now, adoption is largely based on regulatory pressures, especially from prior programs such as Meaningful Use/HITECH. The rapid rollout, adoption, and use of these tools has led to a profusion of tools that may not prioritize the experience of healthcare professionals and patients, which may lead to some of the burden I described above.

I recommend any evaluation focus not only on questions of ROI, but also of how well the tools fit into workflows, information flows, and how well they address the real-world problems our front-line staff and patients have. This is especially relevant, considering questions of burden versus ease of use, intuitiveness, availability of all necessary information to support clinical decision making in the workflow, order entry, and clinical documentation.

Digital health developer perspective

Connie Hwang, MD, Associate Chief Medical Officer, Twin Health

Twin Health is a precision health platform for the prevention, improvement and reversal of chronic metabolic disease. They combine sensors, machine learning and medical science to address and heal the root causes of a disrupted metabolism.

Connie: Where do you see the opportunities for digital health solutions right now?

Digital health solutions are a rapidly evolving opportunity for improving convenience and access, quality of care, and cost-efficiency. Especially among organizations with a strong focus on value-based care, we are seeing continued investment in virtual care and digital health solutions like Twin Health. However, it's crucial that the tools provide three outcomes -- superior clinical outcomes, outstanding member experience, and cost savings. Solutions that can optimally merge digital technology with human care delivery are of greatest interest in achieving sustainable, population-level results.

The healthcare industry has come a long way in assumptions of who can engage in virtual care solutions, with recent years demonstrating increased adoption of telehealth and digital health tools among young and old, urban and rural residents, and across various payer types. However, the “digital divide" and disparities in quality of care remain challenges despite recent technology advances. Payers, providers and employers along with the digital health industry need to continue innovating and promoting more permanent, post-pandemic policies that will improve access to smartphone devices, broadband availability, and support for digital literacy.

Connie: How are provider and payer organizations receiving digital health solutions like yours?

Payers, providers and employers are all seeking ways to improve cardiometabolic health, which recent studies show to be worsening in the US.^[1] As digital health solutions become more mainstream there is growing interest in applying artificial intelligence (AI) to enhance evidence-based care and build personalized experiences.

At Twin Health, our development of the Whole Body Digital Twin^TM leverages AI and Machine Learning (ML) to create a dynamic digital representation of each member's unique metabolism, utilizing real-time data from wearable sensors to continuously monitor and adjust treatment to improve and reverse chronic metabolic disease such as type 2 diabetes.

Connie: What do provider and payer organizations tell you that they want from a digital health solution?

Organizations are evaluating digital health solutions that can effectively engage target populations, achieve clinical results, satisfy their members, and generate a return on investment (ROI), ideally in the nearer term vs. longer term.

At Twin Health, we find that payers, providers, and employers want demonstrable evidence for our digital twin approach and appreciate that our clinical outcomes are validated through two ongoing randomized-control trials (RCTs), including our latest study in partnership with the Cleveland Clinic.

Member satisfaction is key to long term adoption of healthy behaviors, and organizations want to know whether their specific populations can easily access, navigate and benefit from all aspects of a digital health program. We are accustomed to working with diverse populations and frequently share our experiences in implementing our services for members who work 9-5 corporate jobs, long stretches on manufacturing floors, as well as the night shift or all-hours driving for the transport industry.

Even though Twin utilizes advanced AI techniques, it's important that the user experience feels effortless. Twin's smartphone app and virtual care teams incorporate meaningful and actionable insights at each point of the diabetes improvement and reversal journey, starting from education, onboarding, and treatment activation to ongoing support.

Connie: What is most important for employers, providers, and payers?

While there is much overlap in what payers, providers, and employers are looking for to improve cardiometabolic health, there are some components which may resonate more deeply with each client type.

For employers, Twin Health's ability to reverse type 2 diabetes and improve cardiometabolic health represents tangible benefits to employee satisfaction, well-being and productivity. The near-term and ongoing cost savings achieved from diabetes medication elimination, often within a matter of months of starting the program, are equally appealing.

For health plans, we've seen deep interest in the long-term sustainability of clinical outcomes and cost savings achieved through medication elimination and reduction in future urgent care, emergency room visits and hospitalizations. Twin Health's value-based payment arrangement, where our fees are earned only through achievement of key milestones and maintenance of results, is perceived as a major differentiator.

Health systems directly employ and/or are strongly affiliated with primary care practices (PCP). This client type is similarly interested in the benefits of digital health solutions and may be the most proactive in setting expectations for primary care provider engagement. Building trust and avoiding any added burden or abrasion with PCPs is critical.

Digital health quality perspective

Linda Dimitropoulos, PhD, Vice President, Operations, Innovation & Strategy, RTI Health Advance.

Linda: How do you see policy and payment evolving in the digital health space?

The digital health space includes a wide array of applications with different purposes. Digital health applications provide the technology that allows patients easier access to their providers which improves engagement and communication. Digital health applications also allow for better monitoring that empowers patients to be more involved in their care and providers to have the data they need to make better clinical decisions, and in turn, leading to improved outcomes. In addition, there are applications aimed at improving health and wellness on one end of the spectrum and digital therapeutics which are aimed at treating disease on the other. Because of the range of types of applications and novelty, the reimbursement question has been a difficult one, but we are seeing some momentum in some areas.

The Centers for Medicare & Medicaid Services (CMS) is shifting away from fee-for-service payment models to a value-based approach that focuses more patient-centered outcomes and metrics such as patient engagement, preference, and experience. It is hard to figure out a reimbursement path for applications that improve patient engagement or patient experience. Those types of applications will need to demonstrate their value using return on investment modeling. Prescription digital therapeutics, on the other hand, lend themselves to a more traditional approach to reimbursement and there we are seeing some progress.

The National Drug Control Strategy developed by the Biden administration encourages the development of reimbursement strategies to enable the use of prescription digital therapeutics to treat substance use disorder. CMS added a Level II Healthcare Common Procedure Coding System (HCPCS) code for prescription digital behavioral therapy in 2021 paving the way for health plans to cover digital therapeutics. And, in March of this year, the Access to Prescription Digital Therapeutics Act of 2022 was proposed and it is aimed at expanding coverage for prescription digital therapeutics for Medicare and Medicaid.

Linda: Where are healthcare organizations focusing their digital health efforts now? In the near-term?

For the most part, healthcare organizations are very interested in digital health applications but their experience with EHRs is giving many pause about adopting new technology at this time. There seems to be greater interest in connected care technologies such as telemedicine in ambulatory care practices. The experience during the pandemic gave telehealth a big boost and clinicians are interested in maintaining functions like remote visits; however, healthcare organizations are also looking to payers to develop reasonable payment strategies for telemedicine visits.

For other types of digital health applications, most clinicians are waiting until there is sufficient evidence of effectiveness in real-world settings before adopting new technologies and they need assurance that the tools can be integrated with their existing EHRs and into their clinical workflows.

Linda: What are the types of challenges or goals where RTI Health Advance is providing guidance and practical support?

RTI Health Advance conducts studies that generate high-quality evidence of clinical effectiveness and also economic studies to validate the projected cost-savings of adopting a given technology.

Our team also helps with implementation and process improvement that ensures workflow integration by streamlining workflow processes, conducting small tests of change to drive patient outcomes, rolling out new clinical initiatives, and preventing unwanted healthcare costs.

We often function as an independent third-party evaluator that collaborates with developers, payers, and providers to ensure that their applications can be readily implemented into the provider workflow and perform as expected using a value-based contract mechanism.

Linda: What advice do you have for provider and payer organizations to align digital health solutions so that they support larger clinical care and business models?

Given the concerns about clinical and cost effectiveness, I would like to see more pilot testing of these applications within patient or member populations to collect the real-world evidence necessary to fully evaluate the product for the end user.

This is where a value-based contracting arrangement with an independent third-party evaluator could be beneficial. If the cost of a pilot is a concern, and a shared arrangement is not feasible, it may be that these types of pilot studies may need to be funded by the digital health developer as an investment that they can use to further validate their solution and provide necessary outcomes to their various stakeholders.

Find and capture the value of digital health

Whether your organization develops digital health tools and wants to prove your value or your provider or payer organization wants to find and evaluate the best digital health tools and innovations for your goals, we can help. RTI Health Advance offers clinicians, digital health experts, healthcare data research analysts, and seasoned healthcare professionals who support efforts to make care more accessible, equitable, and cost-effective. Contact us.

Source: [1] Karimi, M., Lee, E.C., Couture, S.J.,Gonzales, A.B.,Grigorescu, V., Smith, S.R., De Lew, N., and Sommers, B.D. National Trends in Telehealth Use in 2021: Disparities in Utilization and Audio vs. Video Services. (Research Report No. HP-2022-04). Office of the Assistant Secretary for Planning and Evaluation, U. S. Department of Health and Human Services. February, 2022.