“Digital health? Is that like a rectal examination?”

This was the first comment I heard from an audience member after recently delivering a lecture about digital health to a group of doctors at an esteemed academic medical center.  

To a gastroenterologist like myself, “digital health” sounds more like prodding someone’s derriere with a finger than a revolutionary trend in connected healthcare delivery. The doctor who made this comment snickered when he said it, prompting others in the audience to light up with exuberance.  

I laughed politely, too, as if I had never heard the joke before. Except it was probably the tenth time I’d heard a doctor use the same line.  

This is not a unique reaction among rank-and-file doctors. I’ve lectured to thousands of doctors about digital health, at times to audiences of over 4000 clinicians at professional conferences, and have a reasonable sense of how digital health is perceived in the clinical trenches. I thought it might be helpful to offer my “Top 10 List” of fears and critiques that doctors passionately voice about digital health, along with my typical response. Digital health technophiles may (or may not…) be surprised to hear what doctors think about the role of technology in clinical care; it’s not always pretty. Here are the top 10 fears, paraphrased from actual comments and questions I’ve received from doctors on the lecture circuit:


1. “You’re kidding, right? How in the world do I have time to check all the data? These digital health folks have absolutely no idea how busy my clinic is. Seriously, spend an afternoon with me and you’ll see that every minute is accounted for. There’s no time for all this. I don’t have time to go to the bathroom, much less use an app.”


My typical response

I totally get it. Like you, I see patients in my clinic every week, take care of emergencies in the hospital, and return patient phone calls. I also have very little time to use mHealth apps, monitor wearable data between visits, or electronically transmit tailored education to patients.

How do we move forward with digital health given the time constraints in the clinical trenches? I believe the answer lies in training a new type of specialist called the “Digitalist.” The Digitalist will have your back so you can go about your business in the clinic. This provider does not yet exist, just as “The Hospitalist” did not exist prior to 1996, when Robert Wachter and Lee Goldman coined the term to describe a much-needed clinician to fill an unmet need for inpatient care. Now we have an unmet need for a new clinician, trained in digital health, who will monitor, interpret, and act upon remote patient data. The Digitalist will reside in an e-coordination facility and remotely track data from biosensors, portals, apps, and social media, then combine the data with clinical parameters and knowledge about the patients’ medical history. The Digitalist will bear responsibility for monitoring and acting on the data, and will also be paid in return for improving value and efficiency of care delivery, intercepting crises before they unfold, reducing avoidable admissions, and coordinating care with traditional providers in the clinic.

(Then I show the audience the PowerPoint slide, below).

This picture depicts the evolving model of connected healthcare delivery. The idea is that patients will transmit actively and passively collected data through apps and portals. The Digitalist will monitor the data, and, if needed, contact the patient via EHR portal, telephone, or videoconferencing. If appropriate, the Digitalist will communicate directly with clinicians, inform them of updates, and coordinate the optimal timing of in-person visits. The clinician may also access digital health reports, review the results with the patient, and make further decisions based on the data coupled with the traditional history and physical examination.

If this is successful, then digital health will expand care beyond the traditional clinic visit, use visits more effectively, reduce avoidable admissions, and improve outcomes of care while protecting you from additional work. Time will tell if this future becomes reality, but for many health systems the future has already arrived. Now is the time for doctors to shape the future of digital health for our field before others shape it for us.


2. “What is my liability here? What if remote data show that someone is doing poorly, but nobody checks it? What if a patient dies when there was clear evidence something bad was going to happen? Am I going to get sued?”


My typical response

As things stand right now, this cannot be your responsibility or liability. This is an important issue we need to address before we get too much farther with remote digital monitoring in everyday clinical practice. Until you have a Digitalist watching your back, you cannot take responsibility – including legal responsibility – for monitoring, interpreting, and acting upon the data. As I see it, that will be the Digtalist’s responsibility.


3. “Can you prove that this works? This all sounds great, but until you can prove it to me, it’s just a bunch of toys and gadgets from entrepreneurs trying to make a buck. I need real evidence that this makes a measureable, tangible difference in my patients’ lives”


My typical response

I’m not sure what you mean by “this,” as in “can you prove that this works.” Digital health is a very broad term covering everything from mHealth apps, to wearable sensors, to social media, to EHRs, to big data mining of genomics. Asking if digital health works is a bit like asking if medicine works.

We need to be more specific about the use case. What digital intervention? For what patient population? For what outcome? When we focus our discussion to specific examples, it becomes a matter of empirical science to decide if something works. There is good evidence that certain digital interventions work very well, but also a lack of evidence for others.

But we shouldn’t think of digital health as a binary thing that either works, or doesn’t work.

We need rigorous, hard-fought, meticulous, sufficiently powered, controlled trials to figure out if digital interventions work. This is no different than for any other biomedical advance, whether for cancer chemotherapy, biologics, invasive procedures, or anything else in medicine. We need lots and lots of data, of sufficient quality and quantity, to determine whether a digital intervention is worth our time and money. For example, our approach at Cedars-Sinai is to subject our homegrown biosensors and apps to rigorous research, and then publish the results in peer-review journals (examples).


4. “This may work for wealthy patients with access to care and resources, but what about the rest of our patients?”


My typical response

There is a socioeconomic gradient for use of digital health; this is something we must address. In fact, it may be that digital health should penetrate low SES communities first, because that’s where chronic disease and early mortality is most prevalent. For example, our research team is testing a digitally enhanced “healthy living” intervention in a low SES church community in South Los Angeles. Just having access to a smartphone, which is now commonplace among all SES levels, allows us to deploy apps and even virtual reality, among other technologies. The fact that there is a disparity in digital health does not invalidate it as a science; it only means digital health is like most every other aspect of healthcare delivery. We have to address the disparity, not use it as a reason to avoid digital health altogether.


5. “Maybe young people like using this stuff, but what about our older patients? Those are the people who really need medical care and have comorbidities, but are also least interested in using these devices.”


My typical response:

There is a digital divide with use of health technologies. We find that younger patients are more willing to use digital interventions than older patients. We have seen this with wearable sensors, mHealth apps, and virtual reality in our own research, and others have found the same. Nonetheless, we’ve noticed that many young patients are unwilling to use digital technologies, and many older patients are enthusiastic about them; there are no hard and fast rules. This only means we need to be aware of the digital divide and find ways to overcome it, where possible. There is a tremendous opportunity for research and patient engagement.


6. “What about data security? Will my patients’ data be stolen or lost?”


My typical response:

I am not a data security expert, but I trained when we had paper records strewn about the hospital ward just waiting to be read or stolen. It’s hard to imagine worse data security than that! In any event, data security is a real issue with digital health, but a solvable issue.  


7. “Let me just remind you of the simple facts about healthcare. Use of health resources is not spread evenly across the population like peanut butter. That’s because 50% of the population uses less than 3% of all healthcare resources. Recording their heartbeats, recording how many steps they take, recording how well they sleep, is not going to make hell or beans worth of a difference to the healthcare system.”  


(Editorial note: this is a direct quote from the 2015 Partners Connected Health Conference, where Ezekiel Emanuel delivered the keynote address entitled: “Techo-Skeptic: Being Realistic About How Technology Will Improve Healthcare. It is representative of similar statements I’ve heard from other doctors while on the lecture circuit)

My typical response

There is a difference between “general wellness” devices, like Fitbit or Apple Watch, and medical-grade, FDA approved devices, like AliveCor or Proteus, or the AbStats sensor developed by my group, among many others. This distinction is important, because targeting the “walking well” with commercial wearable sensors is unlikely to change healthcare. But using FDA-approved devices in targeted patients can make a difference; these devices have undergone rigorous testing in defined patient populations, are supported by peer-reviewed literature, and are specifically targeted to improve patient outcomes.


8. “There is too much enthusiasm and hype about digital health. It seems like every study that’s published is positive. Are there any negative results with digital health?”  


My typical response

Yes, there are negative results. For example, my colleagues published a meta-analysis in Annals of Internal Medicine evaluating the impact of electronic health record (EHR) patient portals on outcomes. They concluded:

“Evidence that patient portals improve health outcomes, cost, or utilization is insufficient. Patient attitudes are generally positive, but more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Portals represent a new technology with benefits that are still unclear. Better understanding requires studies that include details about context, implementation factors, and cost.”


But I suspect there are more negative results that haven’t seen the light of day. As Editor-in-Chief of a medical journal, I recently dedicated an entire issue to solely publish “negative results” – here is the announcement. The idea is that we need a safe haven for negative findings, because they can be equally – if not more – important than positive findings. In digital health, we want to know what apps don’t work, what e-messages miss the mark, what sensors are irrelevant, what digital diagnostics are unrevealing, unhelpful, or even harmful, and anything else that may be terrifically non-contributory.


9. “Digital devices are cool, but most people quit using them before long. How can digital health make any difference if our patients refuse to use this stuff?   


My typical response

Digital health is more of a social and behavioral science than a technical science; building an app or device is just the beginning. In order to make inroads with chronic diseases, like diabetes, heart failure, or obesity, we need to change behavior. We already have billions of neuro-hormonal biosensors in our body; the real issue is whether we heed their clarion calls to action. Often we don’t, even though we know better.  

How do we achieve this? I am heavily influenced by Joseph Kvedar’s work at the Partners HealthCare. Dr. Kvedar’s team not only builds and tests digital interventions, but also determines how to optimize apps and sensor within a biopsychosocial framework. His recent book, The Internet of Healthy Things, is a must read to learn why digital health is essentially a behavioral science. Kvedar’s team not only personalizes its apps, but hyper-personalizes its apps. By integrating everything from time of day, to step counts, to the local weather, to levels of depression or anxiety, Kvedar’s apps send pinpoint messages to patients at the right time and right place. As a result, they are making headway in solving some of medicine’s hardest challenges. We should all take note.


10. “This is all well and good, but how will digital health improve the value of care? That is, how can it both improve outcomes, but also save costs? Until you can show that, then insurance won’t pay for this.”  


My typical response

Digital health solutions should provide economic value to health systems; they should be cost-effective compared to usual care. This is the tallest yet most important hurdle to cross. For a hospital or insurer to pay for a digital solution, no matter how inexpensive it is, it should not only improve health outcomes, but also reduce resource utilization. It’s all about “juice for squeeze.” As more and more digital health solutions roll of the assembly line, we need to see them subjected to formal health-economic models. The same applies to any medical innovation, digital or otherwise.




Commentary by Dr. Brennan Spiegel, MD, MSHS