When a digital health company announces a new app, everyone seems to think it’s going to improve health. Not me.
Where I work, in San Francisco’s public health system, in a hospital named after the founder of Facebook, digital solutions promising to improve health feel far away.
The patients and providers in our public delivery system are deeply familiar with the real-world barriers to leveraging technology to improve health. Our patients are low-income (nearly all of them receive public insurance) and diverse (more than 140 languages are spoken). Many of them manage multiple chronic conditions. The providers that care for them struggle with fragmented health records and outdated methods of communication, like faxes and pagers.
So when companies tell us they will cure diseases, drive down costs, and save lives with state-of-the-art technology, I am often hesitant.
More than thirty billion dollars have been invested in digital health since 2011. The resulting technological innovations, such as mobile applications, telemedicine, and wearables, promise to help patients fight diabetes, treat chronic disease, or lose weight, for example.
However, we have yet to see digital health drive meaningful improvements in health outcomes and reductions in health expenditures. This lack of impact is because digital health companies build products that often don’t reach beyond the “worried well” – primarily healthy people who make up a small proportion of health expenditures and are already engaged in the healthcare system.
If we’re designing health apps for those who already have access to healthcare, nutritious food, clean air to breathe, and stable housing, we’re missing the point.
It’s no surprise that health apps are incongruous with the needs of low-income, diverse, and vulnerable patients when these populations are unlikely to be a part of user testing. In addition, the science that technology developers draw from is generated by clinical trials conducted on participants who often do not reflect the diversity of the United States.
Over 80% of clinical trial participants are white, and many are young and male. Women, racial and ethnic minorities, as well as older adults must be included in clinical trials to ensure the results — drawn on not only for product development but also for clinical care and policy — are relevant for diverse populations.
Research conducted by my colleagues at the UCSF Center for Vulnerable Populations demonstrates that patients who are low-income are unable to access many digital health apps. One of our patients testing a popular depression-management app said, “I’d get really impatient with this” and expressed concern that “Somebody that’s not too educated would be like, ‘now, what do I do here?’” A caregiver testing a different app also voiced frustration, saying “Yeah, it’s an app that makes you feel like an idiot.” Yet, despite these barriers, the majority of our study participants (most of whom have smart phones) also express a high interest in using technology to manage their health.
While the private sector is great for innovation, it will fail to improve health in a meaningful way without real-world evidence generated in partnership with diverse patients. In addition, these for-profit companies face long odds to benefit their shareholders in a substantial way without learning how to reach the 75 million patients on Medicaid (including 1 in 3 Californians) who stand to benefit from digital health solutions.
There’s an answer, though, and it’s within reach. To truly improve health outcomes, digital health companies must partner with public health experts and patients to not only ground themselves in evidence-based research, but also build products that meet the needs of all patients.
Along with the compelling business potential of innovating for Medicaid, infrastructure to support this work is growing. For example, organizations like HealthTech4Medicaid are bending the arc of innovation towards the patients who need it most through advocacy and key partnerships with payers, policy makers, care providers, and technology developers.
To truly revolutionize health, let’s demand that technology creators and scalers include diverse end users early and often. Otherwise, the app “for that” will be for them, not for all of us.