What’s needed to scale up digital health in the clinical provider space

As digital technology grows and matures, more and more companies are eyeing the clinical provider space. After all, there are big bucks in healthcare for products that increase access to care, improve outcomes and increase workflow efficiencies, especially if they do so while reducing overall costs. While many digital startups will fall by the wayside, those that show promise face the challenge of scaling up their business in a provider market that still harbors some skepticism about the digital revolution’s place in healthcare.

That’s not to say that doctors don’t see the potential of digital health. In a 2016 American Medical Association survey, 85% of physicians said digital tools are advantageous to patient care. But adoption has not kept pace with that enthusiasm. Dr. Frederick A. Browne, an infectious disease specialist and vice president of medical affairs at Griffin Hospital in Derby, Connecticut, and a member of the AMA’s Physician Innovation Network, says there is “still a little bit of distrust” around digital solutions among physicians generally and older physicians in particular. That’s starting to fade away, though, as people grasp the social determinants and population health advantages of data analytics, remote monitoring and other digital health products, he adds.

According to the AMA survey, the heaviest users of digital tools are primary care physicians and doctors in large and complex practices. The most important elements they look for in adopting technologies are compatibility with liability coverage, data privacy, workflow with EHR systems and billing and reimbursement.

Healthcare Dive spoke with digital health companies and doctors to find out what scalability challenges vendors face and what providers want from digital tools.

Chipping away at distrust

A key challenge for vendors is gaining physicians’ trust. To gain credibility, acceptance and broad adoption, companies need to know what the clinical guidelines say and publish their outcomes. “You have to figure out what exactly you’re shooting for so that you’re hitting it,” says Sean Duffy, co-founder and CEO of San Francisco-based Omada Health, which is using behavior science and digital solutions to help type 2 diabetes and heart disease outcomes. “There are really no shortcuts around that.”

But demonstrating a product’s efficacy is just one of the challenges. Vendors also need to understand how it will impact the clinician’s experience — how they refer, what the reimbursement models are for that health system and what the nuances are for each of those. “You really have to study on a state-by-state, region-by-region level, and there are some areas where you’re going to do well and others where you are not,” Duffy tells Healthcare Dive.

Companies also need to make sure the data their digital tools collect are accurate and relevant to providers. Many wearables on the market today have fairly high error rates. They can tell whether a user walked more or less steps than the previous day, but the lack of consistency undermines their clinical value. “When you are getting into the medical space and getting healthcare providers to use data from digital health technologies and wearables, it’s got to be fairly precise,” says Nicole Stout, VP of medical affairs at Zansors, a Northern Virginia-based startup that makes wearable sensors and apps to help individuals engage their health. “Otherwise, the doctor’s going to look at it and say, it’s not relevant to me.”

Pain points

“Doctors’ main pain points are lack of time, huge work loads, dealing with bad technology and a reimbursement model that doesn’t reward the right things (specifically, quality of care and outcomes vs. quantity of care),” Dr. Kirti Patel, an obstetrician/gynecologist and digital health startup advisor based in Massachusetts, wrote via email to Healthcare Dive. “Highly prized qualities would be solutions that save time, decrease the physician workload, improve interaction with technologies and harness technology to aid the clinician in diagnosis or treatment that ultimately leads to better outcomes for patients.”

To overcome what she calls a “healthy paranoia” about potential solutions, Patel recommends that vendors try to think like doctors and approach their product with the same types of questions providers would have. Is it really needed? Does it improve the current way of doing things? Will it make things worse for doctors or their patients? After answering those questions, the next step is to show providers how their mission and that of the company can align.

Dr. Alex Ding, a diagnostic and interventional radiologist in private practice in the San Francisco Bay Area, looks for four key criteria when considering new digital health services or product: clinical validation, usability, workflow integration and economic value.

“In order for me to confidently use the product and put my own reputation on the line when recommending use to colleagues and patients, I need to have validation evidence that shows its safety and efficacy,” he tells Healthcare Dive.

The technology’s design also has to embody a good user interface and user experience, Ding says. “Doctors still have a bad taste in their mouths from the coerced adoption of not-ready-for-prime-time EHRs and as a result have an immediate knee-jerk skepticism and reluctance to adopt digital tools that have high purported potential but poor usability.”

Dr. Alisa Niksch, director of pediatric electrophysiology and a pediatric cardiologist at Floating Hospital for Children in Boston, agrees. “The data acquired with these new digital methodologies need to be curated in an intelligent way,” she tells Healthcare Dive. “Physicians are already frustrated with managing the IT pathways of their institution’s EHR; they don’t want to have extraneous data overwhelming their workflow, and frankly, their life.”

Usability, financing and more

A corollary to the usability issue, Ding says, is understanding how the technology will enhance or hinder workflow. No matter how clinically valuable a technology may be, if it makes the doctor’s job harder or slower it’s going to face adoption hurdles. “Seamless clinical workflow integration is critical to the long-term success of a technology,” he says. “This is often the hardest piece for a new technology company to realize, understand and implement.”

Finally, doctors want to know if the technology is reimbursable or will improve the physician’s billing and revenue stream, or help patients manage their healthcare costs better. Technologies should have both a clinical and economic benefit, Ding says.

For Browne, the biggest issue when it comes to adopting digital tools is program interfaces and interoperability. Imagine, he says, if you’re building a car and each new piece of equipment has to be interfaced. “We could have the best tire ever, but if it’s not going to fit on the car, it doesn’t really help anybody,” he tells Healthcare Dive. The same goes for healthcare — ultimately, it needs to be functional with everything else.

The other essential quality, Browne says, is that the data the product produces are accurate and actionable and easy to read. That sounds simple, but it’s not. “You can get data analytics that will give you everything about everything, but doesn’t really break down the data that goes to the physicians,” he explains. “I don’t want them to look at it and say, that’s nice. I want them to look at it and say this is what [Browne] wants me to do.”

Other obstacles to scaling up in the clinical provider space include cybersecurity and patient privacy protections. To ensure HIPAA compliance, many providers are wary of integrating new digital health tools with legacy software and are narrowing access to web-based portals that could expose IT systems to viruses and malware, says Niksch. “This, by itself, may be a deterrent for seamless use of digital health platforms within larger institutions with so many disparate databases to manage.”

Another issue is reimbursement. Financial incentives for virtual care visits and remote monitoring devices are still limited and insurance companies don’t provide broad coverage of digital health products. With the uncertainty around the Affordable Care Act and the possibility of millions losing health coverage under a replacement plan, progress on reimbursement is stalled, Niksch says. Any attempt at new reimbursement strategies will likely take a back seat until CMS knows what its 2018 fiscal budget looks like, she adds.

In November, the AMA issued a roadmap for integrating mobile health apps, trackers and sensors in medical care. Among its recommendations are that technologies comply with patient privacy and security laws and provide a standard privacy notice if they collect, store or transmit personal health information.

Strategies for scaling up

So what are some strategies for scaling up in the clinical provider space?

Aligning with known researchers in the their field of expertise is a good way to build street cred and raise the company’s brand. Zansors has partnered with the University of Michigan Sleep Study Lab to test some of its wearables. Omada is in a three-way collaboration with the AMA and Intermountain Healthcare to prevent the onset of type 2 diabetes. The pilot program, which launched last summer, allows patients at risk for diabetes to track their weight and activity either online or via mobile app and provides personal coaching and an online support forum to discuss health concerns.

Companies should also focus on interoperability. Zansors is leveraging smartphone and app technology to combine a patient’s self-reported data and the sensor data that comes in via Bluetooth so that its algorithms at the back end can analyze the data and identify patients at risk of a sleepless night. “We’re able to analyze that data, combine it and push it out as relevant information,” Stout tells Healthcare Dive.

Another way companies can differentiate themselves from the rest of the pack is to offer clear efficiencies. “Have something that works, that doesn’t require extra work for doctors, that doesn’t require an extra set of data questions,” says Jennifer Schneider, chief medical officer at Livongo Health. She adds to make sure the product or service is integrated with the EHR and billing system the provider is working with.

Livongo launched in 2014 selling to large self-insured employers and insurers who foot the bill for people living with diabetes. Since then, they have expanded to large provider groups that want to use their connected glucose meter with individual patients. The key is to design products that optimize outcomes but at the end of the day help the provider do his or her job better and also help to overcome some of the resistance to digital solutions, she tells Healthcare Dive.

“People want to improve healthcare,” Schneider says. “Really understanding who the audience is and who will benefit to reduce those friction points I think is the right way to scale really anything in the healthcare technology space.”