HealthTech: are we even talking the same language?
“The difference between the right word and the almost right word is really a large matter — ’tis the difference between science and pseudoscience”
(with apologies to Mark Twain)
A lack of specificity when talking about terms like Health Technology, Digital Health, Health I.T., and Digital Medicine erodes trust in our industry in two ways: it breeds confusion and it allows pseudoscience to persist. I’ve seen this first-hand, in particular for “Digital Health” with every technology provider (even those tangentially related to health) seeking to use this hot moniker.
Clear classification and shared terminology are critical to fostering understanding and communication in our young industry. If we can’t describe the landscape of HealthTech, how can we then specify the different regulatory pathways, clinical evidence standards and safety monitoring for these technologies?
Biologists have been building on a classification system for biology that was first started by Carl Linnaeus in 1735. This shared taxonomy is still bringing order to the world’s species nearly 300 years later. Some of what Linnaeus proposed was later revised or thrown-out completely, but he and his contemporaries set off down a path of shared understanding rather than accepting fuzzy thinking.
Did you know: Linnaeus’s system was so successful at classifying the world’s species, that he had to create a second invention, the “index card”, to keep up with the number of species being classified in the new system!
And so for my own clarity as much as anything, I’ve sought to reflect and classify within Digital Health:
Digital Health
Starting with the hardest first! The definition that most appeals to me defines Digital Health as “the convergence of the digital and genomic revolutions with health, healthcare, living and society” (Sonnier). This definition recognises the nature of what is happening in health at this very moment: the twin forces of digital and genomics that are driving a revolution rather than an evolution. It is a broad umbrella term but not so broad as to be practically meaningless.
Digital Health is a rapidly evolving space with new terms being coined all the time. Sometimes these new terms better classify solutions to help build shared understanding. But just as often they are used to competitively differentiate solutions (see Livongo’s Applied Health Signals or Akili’s Patient Captivation). As an ex-McKinsey type, I’d love to break down digital health further in a way that’s truly MECE (Mutually Exclusive, Collectively Exhaustive) but perhaps healthcare is more complex than a consultant’s driver-tree or 2x2 matrix?
Thankfully, some agreed terminology is gaining traction in our industry. So I’ve captured those here as an indicative taxonomy of (sometimes overlapping) segments within Digital Health:
Telehealth
Telehealth technology enables traditional care models to be delivered remotely, whether by video-call, telephone or digital documents. The move to Telehealth was driven by the realisation that not everything has to be delivered in-person, but Telehealth is still very much delivered with-person. So in-clinic consults become videoconference consults, written prescriptions become e-prescriptions sent to your email, and printed disease pamphlets become an SMS link to an educational website.
This is low-hanging fruit and in itself will revolutionise healthcare delivery and patient experience. It’s been exciting to watch the adoption of Telehealth-powered care models during the COVID-crisis. Watching this space grow rapidly in 2020, we are reminded that necessity is the mother of innovation implementation…
Telehealth has been a welcome change to bring traditional care into the internet age. However, sometimes it's still awkward for the user and inefficient for the medical team. If we compare Telehealth to another paradigm like banking this becomes more clear: imagine having to video-call with your local banker to ask them to move money between accounts, pay a bill or invest your savings. No doubt a video-call is better than travelling to the bank branch but this is not the digital-first experience that revolutionised banking over the last 15 years. Telehealth is the first step of care-model translation into the internet-age, but not yet the goal of care-model innovation for the internet-age.
Digital Medicine
Digital Medicine is the use of digital tools that improve the practice of medicine to be more personalised, granular and automated. Enter the world of IoT devices, imaging tools, AI-powered diagnostic aids and healthcare chatbots. These solutions require clinical evidence that they functionally work although less often are scrutinised to see if they improve outcomes in real-world settings. The importance of the latter was highlighted by the recent real-world failure of Google’s AI that screens for blindness. Digital Medicine is an exciting area of Digital Health to reinvent workflows for healthcare professionals and healthcare consumers alike.
Digital Therapeutics
Digital Therapeutics are evidence-based digital interventions that prevent, manage or treat a medical condition. This term was first coined by Omada CEO Sean Duffy in their Series B announcement to competitively differentiate Omada’s evidence-based app from a growing field of unproven health apps. This term has been widely adopted as the need to differentiate evidence-based digital interventions from unproven health apps remains an ongoing issue.
Digital Therapeutics are patient-facing by definition and most are being built to address specific conditions and patient cohorts. Critically, a Digital Therapeutic must publish trial results with relevant clinical outcomes in peer-reviewed journals to establish its “therapeutic” benefit, and then continuously follow this up with real-world evidence of impact. This level of evidence is much like a drug or medical device that would also have to substantiate its claims.
Digital Therapeutics offer many potential benefits over standard care, such as reducing demand on healthcare workforces, superseding pharmacological therapies (like Akili’s EndeavorRx) or allowing more personalised healthcare where health consumers choose the intervention that best suits them. Digital Therapeutics can be used as a standalone therapy or in conjunction with more conventional treatments like drugs or in-person therapy.
Many of the “first wave” of Digital Therapeutics relied heavily on one-to-one relationships with remote coaches and doctors working inside their digital programs. These large health workforces are hidden behind these technologies, limiting scalability and driving high costs. However, just now we are starting to see the coming of age of a “second wave” of Digital Therapeutics, Perx Health included. These technologies are publishing evidence of effectiveness above standard care as purely digital products with high scalability.
Digital Care
Service providers who combine solutions from Digital Medicine and Digital Therapeutics with medical and allied health professionals to deliver end-to-end treatment pathways. These are best thought of as digital-first clinics as opposed brick-and-mortar clinics. For example, Digital Care providers may create patient pathways for diabetes prevention using integrated IoT devices for weight control, with patients using a Digital Therapeutic daily and then receiving episodic medical care remotely via Telehealth consults.
The Digital Care segment has evolved partly in response to slow-moving healthcare incumbents who have sometimes struggled to adopt new technology into their clinics and teams. It is easier for incumbents to purchase Digital Health technology wrapped-up as a service, and so avoid the hassle of changing workflows, training staff, and deciding new reimbursement models.
It will be strategically interesting to see what happens in this space as more of healthcare moves to digital delivery. Will current health providers continue to sub-contract to Digital Care companies? Or will they build their own Digital Care services in house? My guess is that many incumbents may realise too late that they have subcontracted away more and more of their core business to Digital Care providers, and in doing so have incubated the growth of their eventual healthcare disruptors.
So what’s not Digital Health?
Health ICT
Information and Communications Technology for the health industry: systems and software to enable health organisation and health providers to do their jobs by electronically connecting different points of care. Think hospital billing systems, doctor-facing EMRs, clinic booking systems and workforce communication tools. Health ICT is generally not patient-facing and does not need clinical claims of effectiveness or high standards of monitoring (much like ICT in other industries).
Health ICT solutions as a category pre-existed Digital Health, pre-existed the internet and spans back to the days of huge mainframe computers taking up the whole bottom floor of a hospital working through COBOL encoded algorithms. While these systems have come a long way since the 1960s and may have moved to the cloud (although I wouldn’t bet on it) they are still fundamentally ICT solutions. Given the continuous improvement of Health ICT over the last 50 years, the current impact is likely to be evolutionary rather than revolutionary.
Health ICT solutions have very close comparables in domains outside of health. This has only become clearer with the move to internet-hosted Health ICT (aka. eHealth). Salesforce is winning market share with its CRM, Salesforce Healthcloud. I’d even suggest that pure video-calls for health delivery is really just the latest form of communications technology in a long progression from telephone, pager, fax machine and email. Videoconferencing is largely an ICT problem, not a health-specific problem, and so Zoom and Skype are rising to be dominant platforms for Telehealth.
Finally, Health ICT is a huge bucket of spend and so deserves its own category. Lumping it in with Digital Health benefits neither industry. For our Digital Health industry, including Health ICT obscures the potential of Sonnier’s twin digital and genomic revolutions. What’s important is that Digital Health is being built on top of the existing and continuing gains from Health ICT in connecting people electronically.
For transparency, separating Health ICT from Digital Health is contentious. I’m not alone with the American Medical Association and Public Health England taking similar positions. But not everyone agrees. Closer to my home in Australia, the National Electronic Health Transition Authority has rebranded to the Australian Digital Health Agency, possibly because the “Digital Health” label makes for a better press release.
The takeaway
Digital Health is standing on the shoulders of giants in Health ICT. But to focus on ICT is to distract from the main game of Digital Health — to revolutionise healthcare delivery with a digital-first mindset. By fostering shared language we can accelerate the impact of Telehealth, Digital Medicine, Digital Therapeutics and Digital Care. These Digital Health categories hold unique promise to scale access and service provision beyond the capacity of stretched healthcare workforces, while also providing continuous care between medical visits and achieving better health outcomes.
