Why aren’t doctors using digital therapeutics?

The digital therapeutics market is set to reach almost $1 billion by 2026 as wearables and apps continue to play an important role in enhancing healthcare. However, the adoption of these tools by healthcare professionals is comparatively low. Senior User Experience Consultant Stewart Anderson explains why.

In the digital age, the technology exists to better capture, analyze and share healthcare data to drive better patient outcomes, to improve their quality of life and ultimately to analyze aggregated, anonymized data to enhance our understanding of the disease and population-level outcomes.

With more than 300,000 healthcare apps available on the market today, it’s clear there is an abundance of healthcare technology available to meet a variety of patient, caregiver, and healthcare professional (HCP) needs. However, although HCPs are often initially excited about the digital therapeutics flooding the market, the uptake of these technologies is low.

This is not due to economic issues plaguing our healthcare systems. Recent analysis from IQVIA Institute for Human Data Science suggests that the use of digital health apps in five chronic disease patient populations could save the UK healthcare system an estimated £170 million per year. Despite these benefits, the National Health Service (NHS) has only just rolled out a 10-year, long-term plan to support a digitally enabled therapy assessment program.

Across the Atlantic, the United States Food and Drug Administration (FDA) is also currently still in the pilot stage of its Software Precertification Program, which is redefining how the FDA regulates digital health devices. Although the consumer sector is using technology to solve customers’ challenges and enhance their experience, healthcare has fallen behind. This is in part due to the complexity of the healthcare industry, coupled with the high and sometimes fatal risks of failing to achieve the outcomes promised.

With 24 years of experience as a research and design professional, Stewart Anderson, Blue Latitude Health’s Senior User Experience Consultant, has honed his skills in digital service design, developing solutions that meet HCP and patient needs at the point of need. Here, he explains why doctors fail to prescribe digital health tools and how pharma companies can help to solve these challenges.

How are digital therapeutics helping patients today?

SA: Wearables and healthcare apps are already improving the lives of people managing chronic diseases, and they have a huge potential to transform their lives in the future.

Consider diabetics, for example. One of the most anticipated features available in the latest continuous glucose monitors (CGMs) is the ability to predict hypoglycaemic attacks before they happen, without users having to take any action at all. Blood sugar levels are automatically sent to the app on the users’ smartphone every five minutes, allowing it to track its direction and speed of travel and alert them up to 20 minutes before hypoglycemia is expected to occur.

This can reduce the frequency and severity of hypoglycaemic symptoms suffered by people with diabetes, by helping them to act preventatively, rather than reactively after their blood sugars have dropped. It can also have the unexpected benefit of encouraging healthier eating, by giving people with diabetes the information they need to be able to snack appropriately – instead of relying on glucose tablets when they are already hypoglycaemic.

Also, whether it’s a child or an elderly loved one who has poor warning symptoms for hypoglycaemic attacks, the peace of mind that comes with knowing your smartphone can alert you when someone you care about needs help, even when they are asleep at night, is worth its weight in gold.

Many everyday benefits only become apparent with a rich understanding of the experience of living with diabetes.

Need to test your blood during an important meeting at work or in a social situation like a dark cinema or nightclub? Instead of having to stop what you’re doing, search for your glucometer in your bag, switch it on, wait for it to be ready, prick your finger with a lancet, and wait for the result, people with diabetes can now glance at their smartphone or smartwatch to get a recent blood sugar level reading in a matter of seconds. At a restaurant and forgot to test your blood before you started eating? Earlier results are one tap away.

Ultimately, keeping a comprehensive diary of blood glucose levels, along with insulin, carbohydrates, alcohol, and exercise, is key to managing type 1 diabetes. The latest CGMs make it truly effortless to track blood glucose levels and, if the patient chooses, to easily share this personal data with their HCPs.

What’s preventing more patients from using these tools?

SA: The digital therapeutics market is like the beauty industry – there is so much out there that you’re overwhelmed with choice. If patients care enough and have the time to do their research, it’s very difficult to identify with any confidence which healthcare apps work and which don’t. After downloading and using four or five apps only to discover that they don’t help them, many simply give up looking.

Cost is another big challenge as wearables and healthcare apps are financially out of reach for many people, with business models ranging from ‘freemium’ – in which the basic service is free of charge but more advanced features must be paid for – to ongoing monthly or annual subscriptions.

There is also a sense of skepticism from the public. Some people with diabetes, for example, perceive that CGMs, though more accurate now than ever before, do not yet provide blood sugar readings as accurately as traditional finger-pricking glucometers. After trialing CGMs in real life, however, it appears that more frequent readings, even if less accurate, empower people with diabetes to better control their blood sugar and stay within target levels. Others fear they could get used to their CGM doing all the work for them and lose the ability to sense for themselves when their blood sugar levels are high or low. Fear of change, even positive change, is nothing new. When creating innovative solutions, it’s crucial to understand the real human preconceptions and concerns that the design needs to address.

Last year, one of the largest life insurance providers in the US announced that all new customers would be required to provide personal healthcare data from a wearable. For customers willing to agree to this pre-condition, the personal data shared has no impact on their premiums, and it will be interesting to see how the market develops and how customer’s attitudes and behaviors evolve.

Often we hear about how these tools are helping patients. How can they make clinicians’ jobs easier?

SA: One of the healthcare apps I worked on was for a new treatment for age-related macular degeneration. If you were eligible, the new treatment was proven to be more effective than the established treatment.

The core design challenge was changing patients’ behavior to improve their adherence to treatment and clinical appointments. The new treatment involved an injection in the eye and for it to work, the patient needed to complete all of their loading doses once a month for almost a year. Understandably, people who had lost their sight were willing to receive the injections to begin with. But, as their sight began to improve, many then stopped as they felt their improved sight was good enough and they preferred not to receive further injections. This caused them to lose their sight again.

The team’s research and design solved this problem by combining behavioral insights with proven psychological principles to identify features that would trigger and motivate patients to adhere. On launch, the smartphone app was up and running quickly, while priming users to associate their health goals with underlying non-health goals that they were more emotionally invested in.

One month is a long gap between appointments, so the app provided a step-by-step plan over the next few months, regular tasks to increase engagement and strengthen recall of their non-health goals ensured that the benefits of the injections remained at the front of their minds. After completing initial research and prototype development, the team carried out qualitative research with real patients and improved the interface to optimize the behavior change elements of the app.

If we continue to use the example of wearables, the nature of the data they can provide has huge potential benefits for clinicians. People living with chronic diseases who manage them poorly often do not record all of their results or choose to only share the ‘good’ results with their HCPs, to impress them or avoid feeling criticized when attending a clinic. Wearables don’t just make recording results effortless; they also normally do not allow results to be edited by patients allowing HCPs to understand what is going on in their patients’ lives.

So, are doctors using digital tools in a clinical setting?

SA: We’re currently seeing more HCPs prescribing apps as a treatment in the US than in the UK. Clickotine, for example, is a personalized smartphone app prescribed in the US for smoking cessation. A study with more than 400 participants found that this app-enabled the majority of users to stop smoking, some permanently and others temporarily.

While digital therapeutics are flooding the market, clinicians’ uptake of these technologies is comparatively low. Why do you think that is?

SA: The lack of real-world evidence is a huge issue. While studies like those for Clickotine are becoming more common, they are the exception rather than the rule. There are many reasons for this. Healthcare is complex and differs hugely from other sectors. The technology needs to be fit for purpose. However, not everyone designing healthcare apps has the appropriate educational and professional background, and the app gold rush has also meant that many developers did not collaborate with their end-users. Without an understanding of the needs and behaviors of the people using them, many tools have not delivered the outcomes they promised.

Getting a sense of the patient’s and HCP’s needs is vital for solving these challenges. Demands on the HCP’s time is one of the biggest problems, and the number of people with chronic diseases is growing, but the resources are not. It’s difficult for HCPs to keep up with what’s available today, and what they can trust and recommend to patients.

We need to help HCPs to make sense of apps and wearables, the data they provide, and where they can add value to themselves and their patients. There is so much data to analyze and understand in a 15-minute consultation. HCPs need the time, training and tools to know how to identify and interpret insights from the data so that they can use them to improve their patient’s treatment and care.

SA: Most apps on a smartphone don’t involve treatments in the body. The well-established stages in the clinical trial process rely on increasing sample size for good reason. Starting with a small sample will limit risks and reveal the side effects. This process is ingrained in pharma, but not in tech. Traditional clinical trials can last for years, meaning technology companies can fear their tool will become outmoded by the time the trial ends, when trials are valuable opportunities to learn and improve the technology over time.

What’s stopping healthcare technology companies from generating robust evidence that counters these objections?

Technology companies need to allow time for trials and classification of software as medical devices, but they are frustrated. They know it is vital to ensure the evidence generated by the technology is watertight, but they are also aware that these tools may not expose patients to the same amount of risk as a medicine.

Additionally, regulators struggle to keep up with technological changes, making it problematic for healthcare tech companies looking to partner with pharmaceutical companies. It also makes market access and reimbursement highly challenging.

Although some regulators, such as the FDA, have developed guidance around digital health, others have not. These are all issues pharmaceutical and technology companies have to navigate to generate the evidence HCPs require.

What could pharma do to help improve the adoption of these tools?

SA: The unifying theme of digital health technology is empowering patients. Giving people control over their health in the future, but the vast majority of patients aren’t currently invested enough to look for an app on their own. It’s about understanding the end user’s needs and designing tools that solve their challenges – that’s the first step in developing innovative technology. Start by identifying and understanding the most valuable problems you need to solve. By doing this we can help more HCPs to believe in and have confidence that these tools work. Then they would recommend them to patients, allowing richer collaboration to improve outcomes and strengthen the relationships HCPs have with their patients.

By Dina Patel