Can the AMA fix the digital health snake oil problem?

It’s funny how topics tend to hit a tipping point when it comes to Internet and social media trending. For digital health and health IT, the past couple months have been a whirlwind of activity since Dr. James Madara, MD, CEO of the American Medical Association (AMA) said, at the AMA Annual Meeting:

From ineffective electronic health records, to an explosion of direct-to-consumer digital health products, to apps of mixed quality — it’s the digital snake oil of the early 21st century. — Dr. James Madara, MD

I haven’t talked to Dr. Madara but my hunch is that he’s gotten exactly the reaction he was looking to get from the industry; namely, he’s gotten high profile, health IT industry pundits and experts to discuss the efficacy and impact of digital health on care delivery. He’s also singlehandedly revived the conversation around the role of care deliverers, namely physicians, in developing healthcare technology and driving tech-enabled innovation. As you consider his statements and the reactions, you need to remember Dr. Madara is the CEO of the AMA, a massively powerful and distinguished organization, so what he said cannot be ignored and very likely would not be dismissed easily.

Snake oil (noun): any of various substances or mixtures sold (as by a traveling medicine show) as medicine usually without regard to their medical worth or properties. — Merriam Webster

Snake oil is a good term. It generates a visceral reaction and, in many respects, Dr. Madara’s comments are spot on. There is a precious dearth of evidence in support of digital technology to improve healthcare (better outcomes, reduced costs, better experience of docs and patients); I’d argue the same lack of evidence exists for digital technology in industries such as education so healthcare isn’t unique in its spend on unproven tech. But it’s worth deconstructing what Dr. Madara actually said to better address the topics.

Electronic Health Records (EHRs)

The health system evolved to what it is today to meet the needs of the industry, driven by both public and private forces. Similar to the health system generally and the often frustrating aspects of it, electronic health records were built, bought, and sold to do exactly what they were intended to do. Initially built to do digital record capture and billing then scaled by the government in an effort to ideally create standardized record systems with the ease of sharing data (the dream of interoperability). The intent of EHRs was never to improve care delivery or make the care of patients more efficient for providers. The intent was also never to provide a bridge for organizations struggling to convert to more value-based contracts and programs. There were studies, well before HITECH and Meaningful Use (MU), that promoted the promise of HIT and EHRs to usher in true transformation in healthcare but those promises haven’t been realized, largely for the reasons the authors cited 10–12 years ago.

This creates a lot of frustration at all levels of care delivery. Providers, like Dr. Madara, are rightfully frustrated to feel like a technology has been forced on them and doesn’t address value-based needs that have become their most pressing issues. Many clinicians also feel EHRs don’t make them more efficient in care. HIStalk had a recent poll on this that found two thirds of respondents felt digital tools (not just EHRs) did not reduce efficiency in care but also found that:

Some of those respondents correctly noted that “efficiency” is in the eye of the beholder, whose personal data capture efforts might — like paying income taxes — detract from their own performance in deference to the greater good.

There’s no easy solution to this problem. Clinicians can take one for the team and hope their documentation creates efficiencies in other areas or maybe get a scribe and offload some of the heavy lifting. Looking at transformation in healthcare, ideally EHRs would play nicer with others and get out of the way of testing and scaling digital health technologies built to deliver care based on value and not volume.

Direct to Consumer Digital Health Products

This isn’t a uniquely “digital” problem for the healthcare system or physicians. Direct to consumer medication marketing has long been a recurring challenge for physicians as they consult with patients “informed” by drug company commercials and websites. Digital technology, or maybe more appropriately digital therapeutics (apps, devices, services, answers, etc), are being marketed directly to consumers and they are using these digital products independently of care providers. It’s worth noting that patients are also using Dr. Google, or even Dr. Bing, to find answers to their questions.

This thing is a Thneed. A Thneed’s a Fine-Something-That-All-People-Need! It’s a shirt. It’s a sock. It’s a glove. It’s a hat. But it has OTHER uses. Yes, far beyond that. You can use it for carpets. For pillows! For sheets! Or curtains! Or covers for bicycle seats! — Once-ler in The Lorax by Dr. Seuss

I think another, potentially more important, question is why is this happening? Are digital health product makers, and Google, convincing consumers they need to use something other than physicians for healthcare information or care? Or are consumer proactively looking for alternatives because of 1) their frustration with accessing care and / or 2) their frustration with the time and attention they get from mainstream healthcare. I’d argue the answers lies somewhere between consumers being targeted and reacting to ads and consumers proactively looking for health assistance in the face of frustration with their current, traditional options. There are also generational changes to more self service everything, including health and healthcare. There’s new data about the ways consumers are starting to access the new front door of healthcare; spoiler alert — the report found people that had used retail clinics preferred them to getting care in traditional settings. This isn’t a new topic for healthcare, it’s just larger and more acute than it was 3 years ago when I wrote about it.

We live in an age of unprecedented access to information, and all the intelligent, targeted marketing that goes along with knowing the types of information people are seeking. Consumers directly accessing health information and digital health and wellness products is unavoidable, whether they seek them out or vice versa. And stopping it is harder than shutting down traveling snake oil salespeople; I’m highly skeptical the AMA, or any provider groups or organizations, can more effectively market their offerings to consumers or compete when it comes to SEO.

So what can be done? The AMA is being proactive with initiatives like Health 2047, a California incubator it’s funding, and should be applauded for that. Unfortunately, that, or anything the AMA does, likely isn’t enough. The role of physicians is changing, and the way consumers access care and information is changing. The only way forward I can see if for physicians to 1) become more knowledgeable about digital health products and services (I learned zero about it in medical school) and 2) ideally start integrating more consumer-facing technology into their practices (this gets at the last section below on “apps of mixed quality).

Apps of Mixed Quality

Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected. — Steve Jobs

The quality of health and wellness apps is a hard thing to assess. Quality has lots of potential dimensions — improved care, reduced cost, better experience, security, ease of data and workflow integration, user engagement, evidence-base, etc. Additionally, quality in healthcare is hard to assess as the same digital app or service can, in one context, be positive and, in another context, be negative. Dr. Jordan Shlain, MD, co-founder of HealthLoop and Tincture, described some of these challenges in a recent interview I did with him. On top of all that, the bar for evidence in medicine is very high.

Despite the challenges, there have been attempts to create marketplaces of health apps, with reviews of quality. Do we all remember Happtique? That was likely the first attempt and was eventually acquired by SocialWellth, which offers a curated marketplace of digital health apps and services mainly used by payors. Lucro is another example of the digital health marketplace concept; my understanding is that Lucro is mainly community driven and they’ve gotten some big brands like HCA to sign on, and also to invest in them. There’s even a mobile health app quality scale (MARS) that has been validated in this study, though I’ve never actually seen it in use.

I’m not sure there is a fix for this. In much the same way that I’m not sure how to fix the market around the lack of evidence for natural remedies (non-regulated substances). Longer term, and maybe not that far off, I think the market, at least the B2B market, will demand more from digital health vendors when it comes to data showing efficacy of their products use. Some new digital health vendors, like Omada and Propellor, have research as a core component of what they do and are building a body of evidence, in the form of peer reviewed publications, in support of the efficacy of their digital therapeutics.

How to combat snake oil (real or perceived)

I think Dr. Madara’s comments, and the sentiment behind the AMA’s statements on health IT and digital health, stem from clinicians not having what they feel is a substantial enough voice in the development and implementation of new technologies in healthcare. I imagine part of the frustration also stems from new services and solutions, in this specific case digital ones, coming into care, effecting care, and not being subject to the same stringent regulations as clinicians and regulated provider organizations; this is not dissimilar to other types of therapeutics that were rightfully targeted as “snake oil” in the past.

The truth is today the rubber meets the road in healthcare at the point of care. The doctor-patient relationship, though significantly undermined by the limited time providers spend with patients and other disincentives, still matters, and will for the foreseeable future. Yes, more consumers are using retail clinics and virtual care, and more and more are finding answers on Google; but care, and the costs of care, is still delivered the way it has been delivered for a while. I remember 4 years ago the storm created when venture capitalist Vinod Khosla wrote that technology would replace 80% of what physicians do and said that technology would replace 80% of physicians. Four years later, the impact of HIT on Dr. Madara’s and many other providers is the opposite as they experience HIT making care less efficient, not more efficient.