digital health

How to Reduce Cardiovascular Morbidity and Mortality in Psoriasis and PsA

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Patients with psoriatic disease have significantly higher risks of myocardial infarction, stroke, and cardiovascular mortality than does the general population, yet research consistently paints what dermatologist Joel M. Gelfand, MD, calls an “abysmal” picture: Only a minority of patients with psoriatic disease know about their increased risks, only a minority of dermatologists and rheumatologists screen for cardiovascular risk factors like lipid levels and blood pressure, and only a minority of patients diagnosed with hyperlipidemia are adequately treated with statin therapy.

In the literature and at medical meetings, Dr Gelfand and others who have studied cardiovascular disease (CVD) comorbidity and physician practices have been urging dermatologists and rheumatologists to play a more consistent and active role in primary cardiovascular prevention for patients with psoriatic disease, who are up to 50% more likely than patients without it to develop CVD and who tend to have atherosclerosis at earlier ages.

According to the 2019 joint American Academy of Dermatology (AAD)–National Psoriasis Foundation (NPF) guidelines for managing psoriasis “with awareness and attention to comorbidities,” this means not only ensuring that all patients with psoriasis receive standard CV risk assessment (screening for hypertension, diabetes, and hyperlipidemia), but also recognizing that patients who are candidates for systemic therapy or phototherapy — or who have psoriasis involving > 10% of body surface area — may benefit from earlier and more frequent screening.

CV risk and premature mortality rises with the severity of skin disease, and patients with psoriatic arthritis (PsA) are believed to have risk levels similar to patients with moderate-severe psoriasis, cardiologist Michael S. Garshick, MD, director of the cardiorheumatology program at New York University Langone Health, said in an interview.

photo of Michael Garshick
Dr Michael S. Garshick

In a recent survey study of 100 patients seen at NYU Langone Health’s psoriasis specialty clinic, only one-third indicated they had been advised by their physicians to be screened for CV risk factors, and only one-third reported having been told of the connection between psoriasis and CVD risk. Dr Garshick shared the unpublished findings at the annual research symposium of the NPF in October.

Similarly, data from the National Ambulatory Medical Care Survey shows that just 16% of psoriasis-related visits to dermatology providers from 2007 to 2016 involved screening for CV risk factors. Screening rates were 11% for body mass index, 7.4% for blood pressure, 2.9% for cholesterol, and 1.7% for glucose, Dr Gelfand and coauthors reported in 2023.

Such findings are concerning because research shows that fewer than a quarter of patients with psoriasis have a primary care visit within a year of establishing care with their physicians, and that, overall, fewer than half of commercially insured adults under age 65 visit a primary care physician each year, according to John S. Barbieri, MD, of the department of dermatology at Brigham and Women’s Hospital in Boston. He included these findings when reporting in 2022 on a survey study on CVD screening.

Dr John S. Barbieri, director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital in Boston

In many cases, dermatologists and rheumatologists may be the primary providers for patients with psoriatic disease. So, “the question is, how can the dermatologist or rheumatologist use their interactions as a touchpoint to improve the patient’s well-being?” Dr Barbieri said in an interview.

Dr John S. Barbieri

For the dermatologist, educating patients about the higher CVD risk fits well into conversations about “how there may be inflammation inside the body as well as in the skin,” he said. “Talk about cardiovascular risk just as you talk about PsA risk.” Both specialists, he added, can incorporate blood pressure readings and look for opportunities to measure lipid levels and hemoglobin A1c (HbA1c). These labs can easily be integrated into a biologic work-up.

“The hard part — and this needs to be individualized — is how do you want to handle [abnormal readings]? Do you want to take on a lot of the ownership and calculate [10-year CVD] risk scores and then counsel patients accordingly?” Dr Barbieri said. “Or do you want to try to refer, and encourage them to work with their PCP? There’s a high-touch version and a low-touch version of how you can turn screening into action, into a care plan.”

Beyond traditional risk elevation, the primary care hand-off

Rheumatologists “in general may be more apt to screen for cardiovascular disease” as a result of their internal medicine residency training, and “we’re generally more comfortable prescribing… if we need to,” said Alexis R. Ogdie, MD, a rheumatologist at the Hospital of the University of Pennsylvania, Philadelphia, and director of the Penn Psoriatic Arthritis Clinic.

photo of Alexis R. Ogdie-Beatty and Joel Gelfand
Dr Ogdie and Dr Gelfand

Referral to a preventive cardiologist for management of abnormal lab results or ongoing monitoring and prevention is ideal, but when hand-offs to primary care physicians are made — the more common scenario — education is important. “A common problem is that there is under-recognition of the cardiovascular risk being elevated in our patients,” she said, above and beyond risk posed by traditional risk factors such as dyslipidemia, hypertension, metabolic syndrome, and obesity, all of which have been shown to occur more frequently in patients with psoriatic disease than in the general population.

Risk stratification guides CVD prevention in the general population, and “if you use typical scores for cardiovascular risk, they may underestimate risk for our patients with PsA,” said Dr Ogdie, who has reported on CV risk in patients with PsA. “Relative to what the patient’s perceived risk is, they may be treated similarly (to the general population). But relative to their actual risk, they’re undertreated.”

The 2019 AAD-NPF psoriasis guidelines recommend utilizing a 1.5 multiplication factor in risk score models, such as the American College of Cardiology’s Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator, when the patient has a body surface area > 10% or is a candidate for systemic therapy or phototherapy.

Similarly, the 2018 American Heart Association (AHA)-ACC Guideline on the Management of Blood Cholesterol defines psoriasis, along with RA, metabolic syndrome, HIV, and other diseases, as a “cardiovascular risk enhancer” that should be factored into assessments of ASCVD risk. (The guideline does not specify a psoriasis severity threshold.)

“It’s the first time the specialty [of cardiology] has said, ‘pay attention to a skin disease,’ ” Dr Gelfand said at the NPF meeting.

Using the 1.5 multiplication factor, a patient who otherwise would be classified in the AHA/ACC guideline as “borderline risk,” with a 10-year ASCVD risk of 5% to < 7.5%, would instead have an “intermediate” 10-year ASCVD risk of ≥ 7.5% to < 20%. Application of the AHA-ACC “risk enhancer” would have a similar effect.

For management, the main impact of psoriasis being considered a risk enhancer is that “it lowers the threshold for treatment with standard cardiovascular prevention medications such as statins.”

In general, “we should be taking a more aggressive approach to the management of traditional cardiovascular risk factors” in patients with psoriatic disease, he said. Instead of telling a patient with mildly elevated blood pressure, ‘I’ll see you in a year or two,’ or a patient entering a prediabetic stage to “watch what you eat, and I’ll see you in a couple of years,” clinicians need to be more vigilant.

“It’s about recognizing that these traditional cardiometabolic risk factors, synergistically with psoriasis, can start enhancing CV risk at an earlier age than we might expect,” said Dr Garshick, whose 2021 review of CV risk in psoriasis describes how the inflammatory milieu in psoriasis is linked to atherosclerosis development.

Cardiologists are aware of this, but “many primary care physicians are not. It takes time for medical knowledge to diffuse,” Dr Gelfand said. “Tell the PCP, in notes or in a form letter, that there is a higher risk of CV disease, and reference the AHA/ACC guidelines,” he advised. “You don’t want your patient to go to their doctor and the doctor to [be uninformed].”

‘Patients trust us’

Dr Gelfand has been at the forefront of research on psoriasis and heart disease. A study he coauthored in 2006, for instance, documented an independent risk of MI, with adjusted relative risks of 1.29 and 3.10 for a 30-year-old patient with mild or severe disease, respectively, and higher risks for a 60-year-old. In 2010, he and coinvestigators found that severe psoriasis was an independent risk factor for CV mortality (HR, 1.57) after adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidemia.

Today, along with Dr Barbieri, Dr Ogdie, and others, he is studying the feasibility and efficacy of a proposed national, “centralized care coordinator” model of care whereby dermatologists and rheumatologists would educate the patient, order lipid and HbA1c measurements as medically appropriate, and then refer patients as needed to a care coordinator. The care coordinator would calculate a 10-year CVD risk score and counsel the patient on possible next steps.

In a pilot study of 85 patients at four sites, 92% of patients followed through on their physician’s recommendations to have labs drawn, and 86% indicated the model was acceptable and feasible. A total of 27% of patients had “newly identified, previously undiagnosed, elevated cardiovascular disease risk,” and exploratory effectiveness results indicated a successful reduction in predicted CVD risk in patients who started statins, Dr Gelfand reported at the NPF meeting.

With funding from the NPF, a larger, single-arm, pragmatic “CP3” trial (NCT05908240) is enrolling 525 patients with psoriasis at 10-20 academic and nonacademic dermatology sites across the United States to further test the model. The primary endpoint will be the change in LDL cholesterol measured at 6 months among people with a 10-year risk ≥ 5%. Secondary endpoints will cover improvement in disease severity and quality of life, behavior modification, patient experience, and other issues.

“We have only 10-15 minutes [with patients]…a care coordinator who is empathetic and understanding and [informed] could make a big difference,” Dr Gelfand said at the NPF meeting. If findings are positive, the model would be tested in rheumatology sites as well. The hope, he said, is that the NPF would be able to fund an in-house care coordinator(s) for the long-term.

Notably, a patient survey conducted as part of exploratory research leading up to the care coordinator project showed that patients trust their dermatologist or rheumatologist for CVD education and screening. Among 160 patients with psoriasis and 162 patients with PsA, 76% and 90% agreed that “I would like it if my dermatologist/rheumatologist educated me about my risk of heart disease,” and 60% and 75%, respectively, agree that “it would be convenient for me to have my cholesterol checked by my dermatologist/rheumatologist.”

“Patients trust us,” Dr Gelfand said at the NPF meeting. “And the pilot study shows us that patients are motivated.”

Taking an individualized, holistic, longitudinal approach

“Sometimes you do have to triage bit,” Dr Gelfand said in an interview. “For a young person with normal body weight who doesn’t smoke and has mild psoriasis, one could just educate and advise that they see their primary care physician” for monitoring.

“But for the same patient who is obese, maybe smokes, and doesn’t have a primary care physician, I’d order labs,” he said. “You don’t want a patient walking out the door with an [undiagnosed] LDL of 160 or hypertension.”

Age is also an important consideration, as excess CVD risk associated with autoimmune diseases like psoriasis rises with age, Dr Gelfand said during a seminar on psoriasis and PsA held at NYU Langone in December. For a young person, typically, “I need to focus on education and lifestyle … setting them on a healthy lifestyle trajectory,” he said. “Once they get to 40, from 40 to 75 or so, that’s a sweet spot for medical intervention to lower cardiovascular risk.”

Even at older ages, however, lipid management is not the be-all and end-all, he said in the interview. “We have to be holistic.”

One advantage of having highly successful therapies for psoriasis, and to a lesser extent PsA, is the time that becomes available during follow-up visits — once disease is under control — to “focus on other things,” he said. Waiting until disease is under control to discuss diet, exercise, or smoking, for instance, makes sense anyway, he said. “You don’t want to overwhelm patients with too much to do at once.”

Indeed, said dermatologist Robert E. Kalb, MD, of the Buffalo Medical Group in Buffalo, NY, “patients have an open mind [about discussing cardiovascular disease risk], but it is not high on their radar. Most of them just want to get their skin clear.” (Dr Kalb participated in the care coordinator pilot study, and said in an interview that since its completion, he has been more routinely ordering relevant labs.)

Rheumatologists are less fortunate with highly successful therapies, but “over the continuum of care, we do have time in office visits” to discuss issues like smoking, exercise, and lifestyle, Dr Ogdie said. “I think of each of those pieces as part of our job.”

In the future, as researchers learn more about the impact of psoriasis and PsA treatments on CVD risk, it may be possible to tailor treatments or to prescribe treatments knowing that the therapies could reduce risk. Observational and epidemiologic data suggest that tumor necrosis factor-alpha inhibitor therapy over 3 years reduces the risk of MI, and that patients whose psoriasis is treated have reduced aortic inflammation, improved myocardial strain, and reduced coronary plaque burden, Dr Garshick said at the NPF meeting.

“But when we look at the randomized controlled trials, they’re actually inconclusive that targeting inflammation in psoriatic disease reduces surrogates of cardiovascular disease,” he said. Dr Garshick’s own research focuses on platelet and endothelial biology in psoriasis.

Are Clinicians Prepared to Harness the Power of Digital Health?

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All medical students should be educated in digital health literacy

Image of a doctor sitting at desk interacting with virtual reality and checking electronic medical records of his patients

While digital technologies from smartphones to social media permeate almost every facet of our daily lives, their adoption and application on the frontlines of healthcare remain limited. Despite this, digital health as an industry has seen explosive growth in recent years, with record levels of private investment pouring into start-ups creating mobile health apps, telehealth platforms, wearable devices, artificial intelligence for automated disease diagnosis, tools for health data management and analytics, and much more.

The FDA approval of the first prescription digital health tool in 2017 dispelled doubts of whether digital health could generate rigorous and credible evidence of improving patient health outcomes. Since then, the FDA has approved or cleared digital technologies for the diagnosis, management, and prevention of an increasingly diverse range of medical conditions — from chronic insomnia and stroke to asthma and diabetic eye disease. In many cases, these digital tools have been clinically proven to be equivalent to, or in some cases superior to, previous gold-standard interventions.

Given these developments, we believe that digital health will affect every corner of healthcare. And yet, current and future clinicians are not prepared to harness its full potential.

Despite the promise of digital health tools to bring clinically-proven care to patients with unprecedented levels of convenience, and despite the overwhelming eagerness of patients to embrace digital health tools, physicians remain hesitant. They often express frustration over not knowing which digital health tools to choose, how to integrate them into the existing clinical workflow, and how to talk about them with patients.

Fortunately, there are indications that clinician attitudes are shifting. In 2016 and 2019, the American Medical Association (AMA) conducted studies of physicians’ motivations for the adoption of digital therapeutics. According to results of the 2019 refresh, there has been an uptick in the number of physicians who see an advantage to using the technology, regardless of that physician’s gender, specialty, or age. But this is not enough; without any formal education or standardized guidelines to help them, current clinicians interested in digital health still have to navigate the landscape on their own.

It is time to include digital health literacy as a core competency in medical training, starting in medical school.

We decided to deploy a digital health literacy course at our institution, Stanford Medical School. Since there exists no best practices for how to design such a course, we formulated it ourselves and called the course The Digital Future of Health Care. Crucially, the goal of the course was not to teach students how to create these tools, but rather to understand what these tools can and cannot do, and to think critically about their implementation. Since medical students will not only be future clinicians, but also future educators and leaders responsible for spearheading the cultural shift around digital health, we also sought to improve their ability to converse confidently and knowledgeably about these tools.

We intentionally recruited students who had no prior experience with digital health or who were skeptical about its applications. While medical students were the primary target, we also included physician assistant students, business school students, and genetic counseling students. This interdisciplinarity reflects the variety of stakeholders in our complex healthcare system and our awareness that healthcare will increasingly be delivered through teams of providers, not just the lone clinician. The fact that this course became the most over-enrolled elective of the year, despite its newness, reaffirmed the importance of bridging this knowledge gap.

Our course structure reflected our goals. We began with an overview of digital health in large part to dispel common misconceptions about it, for example, that adopting digital health risks displacing the human clinician or that digital health is only suitable for young and tech-savvy clinicians and patients. The bulk of the course covered the most significant applications of digital health: telemedicine, mental and behavioral health, clinical trials and precision medicine, and population health — emphasizing tools with a demonstrated track record of clinical utility and with existing traction among patients and clinicians.

Any attempt to improve digital health literacy among medical trainees ought to empower them with practical and broadly transferable frameworks for thinking critically about the strengths and limitations of a given digital health intervention. Interspersed throughout the course were sessions on cultivating the clinician-patient relationship, cultural and systemic barriers to healthcare innovation, models of healthcare delivery and reimbursement, and the process by which digital health tools are clinically validated and implemented.

We also found that making room for debate allowed students to learn from each other’s experiences, and gave them opportunities to formulate and articulate their own perspectives, especially around ethically ambiguous topics. Major questions discussed included: what biases might be inherent in artificial intelligence algorithms? How can we improve accessibility of digital health solutions for underserved populations? What ethical considerations should clinicians keep in mind when deciding whether to use a digital health tool? How can we encourage patients to adhere to treatment plans involving digital health?

By the conclusion of the course, nearly 90% of all students were convinced of the ability of digital technologies to improve healthcare and 85% believed the course should be required of all medical students.

Digital health is poised to radically transform how care is delivered to patients. While clinician culture is notoriously resistant to change, we believe the propagation of digital health is inevitable. Equipping students with critical thinking skills about the strategic implementation of digital health tools will prepare them to be future clinicians who can provide the best care possible for their patients.

Top trends that will define digital health in 2019

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Government health workers in Zambia uses data visualization software to track malaria transmission in real time so that his team can treat, prevent, and eliminate cases before they spread further. Photo: PATH/Gabe Bienczycki.  

Zambian government health workers use real-time data updates from their region, and data visualization software, to track malaria cases and accelerate treatment and prevention.

 

PATH’s digital health team shares five trends that are likely to improve accessibility, affordability, and quality of health care for millions of people around the world.

Over the past decade, digital health has embedded itself in our daily lives. Wearables and smart devices keep track of everything from calories burned to heart rate to sleep cycles to stairs climbed, providing users a dashboard of data and insights about their health and well-being. Expert medical advice is no longer confined to a doctor’s office, as video consultations and messaging services connect people to medical professionals from the comfort of their own home.

But perhaps nowhere do developments in digital tools and services hold more promise to improve an individual’s health outcomes than in low-resource settings across Africa, South Asia, and elsewhere.

Here are five promising trends that PATH is optimistic will improve accessibility, affordability, and quality of treatment for millions of people around the world:

14750.jpeg A health care worker in Rwanda fills out paperwork. Photo: PATH/Doune Porter.

A healthcare worker in Rwanda works at the intersection of digital and paper records. PATH/Doune Porter.

  1. Health data privacy and security for all

People everywhere are calling for increased security to protect their personal data and for a greater understanding of the rights they have over this information. Because health information systems gather the most sensitive information about us, ensuring the privacy and security of these systems is vital. At the same time, researchers at universities and in the private sector rely on health data to inspire medical breakthroughs. As global health care systems undergo digital transformation, it is essential to get the balance between security and accessibility right.

In response, the global community is painting a more nuanced understanding of how anonymity, de-identification, and big data work together, and how consumers can benefit from digital health without feeling at risk. Inspired by the European Union’s General Data Protection Regulation, governments such as Kenya are writing new laws and guidelines to clarify the rights of individuals over their digital data. And organizations, including Understanding Patient Data, are exploring how to make sure patients are fully informed about their digital rights, giving them greater power over their health data. This year, the global conversation about privacy and security will be codified into new guidelines for governments, technology developers, and health workers.

2. AI is a powerful tool for the next-gen health worker

Artificial Intelligence (AI) and machine learning open up powerful avenues for digitally enabled health care. For example, computerized learning systems can free up frontline health workers’ time by automating tasks like supply management. By tracking which medicines and supplies are available and where they are running low, these systems will streamline inventory management with computer precision, enabling health workers to spend more time directly with patients.

In addition, machine learning tools can assist in the detection of and response to potential disease outbreaks, allowing global systems to respond quickly to prevent epidemics. Applying machine learning could help reduce errors in contact tracing—a method used to find and monitor individuals potentially exposed to serious infectious diseases like malaria or Ebola. AI can also use health care data collected through routine visits to assess treatment options, helping health workers treat common health problems within their communities. We believe that 2019 will be a year when AI is unleashed on large data sets and machine learning is applied to diseases that disproportionately affect communities in low-resource environments.

3. Can we harness social media as a social good?

Billions of people connect through Facebook, WhatsApp, Weibo, and other social media platforms. But the impact of social media is both good and bad.

While these platforms grant unprecedented access to health information, it’s not always accurate, and in some cases it’s misleading. Researchers are also studying the role of social media consumption in exacerbating mental health issues like anxiety and depression.

But social media has proven it can advance health equity. For example, a new mother living in rural Kenya can message a Facebook chatbot to receive information on infant care, saving her half a day’s travel to the nearest health outpost. Adolescents can avoid social stigma by anonymously chatting online with providers about sexual and reproductive health information. Rural health workers can ask their colleagues for advice through WhatsApp, making it easier to manage difficult cases even when they’re hundreds of kilometers apart. And pilot programs, like the World Health Organization’s partnership with Google Fit, are exploring how personalized social media can be used to influence or “nudge” people toward healthy behaviors and choices.

Individuals need more resources to navigate information they’re relying on to make health choices. Governments, social media platforms, and civil society are all looking for new ways to promote good sources of information and rebuild trust in social networks. In 2019, the conversation about how we can make social media a social good will continue with a greater focus on truth and trust.

4. Digital systems and products will talk to each other

The next era of digital health won’t be defined by cutting-edge technologies—instead it will be defined by the seemingly simple connections that enable digital health tools to work together. This includes interoperable software that allows individual programs and tools to “talk” to each other and share information. Guided by global standards, developers and data scientists are ensuring that interoperable systems can equip health workers and global experts with a complete picture of health services and opportunities for improvement in individual communities and entire countries alike.

We believe 2019 will be a year of great consolidation in digital health. Digital systems that used to function independently, or as standalone products, are being integrated into a network of tools. Communities of practice like OpenHIE are bringing together software developers and health care practitioners to define how systems can exchange health information. Private-sector companies are being encouraged to adopt the same global standards used by open source software so that health information systems around the world can speak the same language. Active government participation in groups like the Health Data Collaborative is ensuring that new tools work together and meet country needs from day one. The connections between systems will bring greater connections between people, growing a strong, vibrant global digital health community.

5. The digital health revolution will truly go global

The right conditions and environment are crucial to harnessing the latest and greatest health innovation. Work on the broader country “enabling environment” is underway to strengthen the governance and thoughtful application of digital health tools. This includes boosting frontline health workers’ digital literacy as well as improving the capability of data analytics in global health. It is not enough to collect data. It must be translated into information that helps decision-makers and health workers do their jobs. What’s more, governments are creating policies, strategies, and investment plans that guide digital health at both the global and national levels.

Technology, policy, and health systems are aligning at the global level, drawing upon decades of insights and lessons to transform digital health worldwide. Underpinning this effort is a collaboration between PATH and the World Health Organization, which focuses on developing a global digital health strategy. This will enable investors, governments, and technology developers to rally behind a shared set of principles and approaches for digital health, opening up new cross-sector collaboration. Pieces of this puzzle that were once scattered across the globe are now being assembled into a picture of revolutionary digital health systems.

The human face of digital health

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A Digital blood sugar meter, next to an syringe with needle for insulin treatment -

A Digital blood sugar meter, next to an syringe with needle for insulin treatment

Speed read

  • Digital health can be ‘solutions looking for a problem’
  • Data protection not developing as fast as technology
  • Algorithms can simplify and standardise, but ‘medicine is subjective’
After spending the first five years of his life in Bihar, one of India’s poorest states, Vishwajeet Kumar got to travel the world. He kept coming back home every year – and that back and forth was a big part of how he came to see healthcare differently.

“I was at this intersection of two worlds who were not talking to each other,” he says. “West versus East.”

Kumar now works to weave the best of those worlds together. He is critical of the kind of biomedical training he says leaves little room to value the cultural models and social norms in the communities doctors work in.

One example is hypothermia. It was one of the reasons new-born babies were dying when 15 years ago Kumar set up the Community Empowerment Lab in Uttar Pradesh, a state that accounts for a quarter of the country’s neonatal deaths. Yet 16 months after the Lab’s work began in rural Shivgarh, mortality dropped by 54 per cent.

“It is almost 17 times faster [than] if I would have simply looked at a government effort to reduce mortality,” says Kumar. The difference, he says, is simply to start by listening to people, and seeing them as part of the solution.

But as digital technologies take centre stage in healthcare, is low-tech, human-centred care doomed to stay in the periphery ‒ or is it needed more than ever?

Plugged in

Behind the achievements of Kumar’s Lab was the introduction of community health workers who do the listening, and help design solutions with the people they serve.

These workers provide the magic of human interaction. They’re also a bridge between patients and the health system. Healthcare staff “provide a two-way flow of information for those who struggle to reach a facility”, says Hana Rohan, assistant professor in social science at the London School of Hygiene & Tropical Medicine in the UK.

That function often comes with the support of digital tools. One example is Mobile Kunji, an audio app that was rolled out in Bihar in 2012, which helped workers raise awareness about family planning, according to Rohan. “This was a job aid combining a deck of 40 colour-coded cards with illustrations and a supportive audio IVR [interactive voice response] system,” she says.

There’s no shortage of healthcare apps. Over the past 20 years, the field of mobile health (mhealth) has evolved from the simple beginnings of emergency response and telemedicine to data collection tools, and eventually more sophisticated apps now beginning to be used at scale. In May this year, the World Health Assembly passed a resolution on mHealth – a sign of recognition of its power as a healthcare tool.

Bigger, more integrated

Patricia Mechael, co-founder of the non-profit organisation HealthEnabled, explains that health apps have so far been largely disconnected from the healthcare system. But there are signs of a shift, she says, with apps increasingly getting integrated into electronic systems that manage healthcare information, for example, or disease surveillance.  “There is a fair amount of activity that’s happening throughout the world to move in this direction.”
Although others see slower moves towards integration, there’s agreement that governments are beginning to take the lead to develop standards, architectures and policies to connect digital health tools and scale up their use.

Part of the appeal is that without integration, countries won’t see the benefit, says Mechael – and that includes the data being captured by digital tools. But data protection policies aren’t developing quite as fast as the technology, raising privacy concerns.

“It is more than a technical issue (of encryption etc.),” says Elaine Baker, a digital health specialist with PATH in Tanzania. “It involves thought being given to exactly which health workers and other data users have access to – which types of data, about which clients, in which circumstances.”

Simpler, more human

Yet, the drive towards ever-more digital systems also raises questions over the human factor in care – how to put the needs of patients and health workers first.

Algorithms will simplify and standardise, but medicine is subjective, says artist and Bellagio resident Asim Waqif – and that makes having a relationship with a doctor even more important at a time when technology puts a vast amount of information on anyone’s fingertips.

“Ultimately even quite complex algorithms still come down to [the] individual skills of the practitioner who’s looking after the patient,” says Ian Lewis, a psychiatrist at Groote Schuur Hospital in Cape Town, South Africa.

How to get the best of both worlds

Mechael says it’s often the simpler tools that are most effective. “A lot of times I think we rush to the new shiny object in the app space, but don’t think enough about even just the ability to communicate via voice through mobile phones,” she says.

For Lewis, using the conventional phone is often more useful than an app to contact patients, especially in a practice like psychiatry where background information from families is important. “The other low technology is just sending text messages to people to remind them to take their medication,” he says, and that’s worked well with drugs for chronic conditions such as hypertension or TB. “The risk with that is obviously confidentiality.”High-tech solutions are too often the default, says Alexa Koenig, executive director of the Human Rights Center at the University of California, Berkeley School of Law in the United States. But sometimes simple behavioural changes are more effective, and we need to start appreciating the full range of solutions. “When is it more appropriate to go to low-tech solutions, or even no-tech solutions?” she asks.

“The key is to listen to what the problem to be solved is, and then propose a solution that is tailor-made for that problem,” says Veronica Garea, executive director of Fundación INVAP in Argentina. “Maybe it’s not shiny, it’s not flashy, it’s not sexy enough, but it’s what people need.”

There is also a tendency to wipe out conventional methods when innovations come in, according to Cosmas Bunywera, coordinator at Peek Vision in Kitale County, Kenya.

Another problem is that tech designers don’t necessarily factor in cultural differences, says Bunywera. “The reason is that sometimes they are very far away from where the tech will be used.”

Baker believes the separation between health professionals and IT developers exacerbates this. “IT people can design tools that are solutions looking for a problem, rather than really focusing on the health problems and tools which really address them in a sustainable way.”

Back at the Community Empowerment Lab, Kumar echoes the sentiment. “Many at times I feel there are solutions looking for a problem. We’re saying, can we reverse it?”