The Double-Edged Sword of Digital Health (The Downside Will Surprise You)

“You know I, need to choose the correct path, change the aftermath, 
Before she sings my song, ‘cause it may not be long: 
Karma’s a double-edged sword. Karma’s a double-edged sword.” 
- Cunninlynguists, Karma

In 2015, I published the phrase “digital therapeutics” in a research paper, and defined this new field as: “evidence-based behavioral treatments delivered online that can increase accessibility and effectiveness of health care.” It’s amazing to see there are now dozens of startups and investors that continue to create digital therapeutics to treat chronic pain, depression, anxiety, asthma, and other conditions. The first part of digital health’s mission—increasing access to care—is progressively being achieved.

The Sharpened Edge: Access to Care

Digital therapeutics are intrinsically designed to be scalable through technology. While the original Diabetes Prevention Program (DPP) clinical trial enrolled 1,079 participants across 28 cities in its lifestyle treatment arm, online DPPs can enroll several thousand participants in a single week alone. By signing up employers, payers, and systems, tens of thousands of people can gain access to digital therapeutics overnight by receiving an email the next day to sign up, and being enrolled in treatment by week’s end. As investor Andreessen Horowitz put it, Software is Eating the World and Getting the World to Stop (Over) Eating.

Furthermore, policy and reimbursement channels enabled digital therapeutics to access traditional payment channels just like any other medical treatment. My publications encouraged national organizations like the CDC and ICER to recognize online DPPs as being as good as in-person ones, and Medicare to also reimburse these treatments for seniors starting in 2018. In an earlier article, I shared my story of being a young clinician working at the VA and struggling to get my low-income Veteran patients to come to the VA hospital for weekly treatment. So it is tremendously inspirational to see that in a few short years, digital therapeutics significantly increased access to care—helping over 100,000 patients—more than I could treat in several lifetimes as an individual practitioner.

The Unsharpened Edge: Effectiveness of Care

But the second part of digital health’s promise—effectiveness—is more equivocal. High-quality digital health programs certainly show efficacy in carefully-controlled research studies (in which participants and analyses are carefully chosen), but most programs have lower effectiveness when deployed in the real world. Why? Because digital health’s greatest strength—accessibility—also inevitably lowers engagement rates, thus being a double-edged sword.

The ironic issue with increasing access to care via digital therapeutics is a lot of participants sign up for online treatment who would have never shown up to an in-person treatment. That’s great if the reason they didn’t come in-person is because of logistics. But requiring a participant to show up in-person also filters out people who are unmotivated and would not have followed through with treatment.

So the inadvertent downside of an easy 15-minute online sign-up process is that it enrolls people who simply want to ‘kick the tires’ of the program, but not truly want to engage. Just as most consumers have gotten used to downloading free apps, trying them once or twice, and never opening them again, digital therapeutics often sees higher-than-normal dropout rates when compared with the real world. In order for a digital therapeutic to be effective, it must be more aligned with psychology. Here’s why:

Medicine vs. Psychology: A Philosophical Distinction

As a specialist in Behavioral Medicine, I straddle the line between medicine and psychology, and the difference between the two fields is less about treating the physical vs. the mental, and more about a fundamental distinction in philosophy. While the following is a generalization, I’ve found it to be a useful framework for thinking about the doctor-patient relationship in both fields.

In medicine, the doctor is the agent of change. A patient comes to their doctor when they’re sick and says “Hey Doc, I got this problem…” The doctor figures out what’s wrong, and attempts to cure the patient, usually with a pill or procedure. In this relationship, the doctor is the active curative agent, and the patient (as long as they consent) is a passive recipient of treatment. This dynamic has fueled Americans’ obsession with first asking for the ‘quick fix’ of curative pills (e.g. weight loss drugs) or procedures (e.g. bariatric surgery) that treat complex biopsychosocial issues as purely medical ones.

In contrast, in psychology, the patient is the agent of change. When a patient comes to me, and says “Hey Doc, I got this problem…”, I also try to figure out what’s wrong, but I explicitly tell my patients, “I cannot cure you, I can only give you the knowledge, skills, and support for you to cure yourself.” This is a radically different stance. Without the patient’s motivation and effort, no brilliant diagnosis or treatment plan will do them any good. Which is why I always tell patients:

“Insight without behavior change is worthless. The important part is to implement these insights into your everyday life."

When it comes to behavioral treatments, patients must be empowered to take charge of their own care by actively adhering (vs. passively complying) to recommendations. the doctor plays an important role as a co-pilot (not the curer) to help them navigate the murky waters ahead.

The Path to Engagement Starts with ‘Digital Triage’

Thus, the future of digital therapeutics is to better screen participants for motivation through what I call ‘Digital Triage.’ The idea is never to restrict access to care to those who would benefit from it. But since behavioral treatments fundamentally rely on the patient’s motivation to succeed, they should ensure participants are willing and able to change. Psychologists use models like the transtheoretical model to identify what ‘stage of change’ an individual is in. Digital therapeutics are best suited for those in the later stages of preparation and action (rather than precontemplation or contemplation). Using predictive analytics, psychologists can triage participants up-front using a combination of demographic, questionnaire, and behavioral data to predict who is most likely to engage and succeed in a behavior change program.

If participants are currently not ready to change but thinking about it (i.e. contemplation stage), they can either be enrolled in a ‘pre-intervention’ base camp to prepare them for change, or put on a waiting list and checked-in on again in a few months to see if they have progressed on their own. However, for patients that are in the precontemplation stage (i.e. in denial about needing to change in the first place), they are not currently suited for treatment until they open up. Doing such ‘digital triage’ would ensure valuable resources are directed to those who both need it and are ready to use it.

The Rise of Consumer Digital Therapeutics

While it seems counterintuitive to erect barriers to care, if you’re a student of psychology, you know that personal investment improves engagement. When I helped run clinical trials at UCLA, we provided completely free treatment for patients with anxiety disorders, and even paid participants a few hundred dollars for all of the extra research study visits. What ended up happening was that we had an high dropout rate, because the treatment was free and there was no consequence to cancelling last-minute or even no-showing to appointments.

While the treatment was valuable (and would have been expensive outside of a trial), many participants didn’t take it seriously because it didn’t cost them anything. However, as soon as we introduced a $5 copay/cancellation fee per session (which still ended up being free due to compensating them for the research visits), our cancellation rates plummeted. Obviously copays are not the easy fix for patient engagement, but this experience shows that patients having some ‘skin in the game’ ensures resources are used effectively.

Enterprise digital therapeutics companies that dominate markets will continue to have great impact and grow as long as reimbursement continues. But I concur with investors Kara Nortman and Eduardo Saverin that innovation will increasingly come out of the next generation of consumer-oriented digital therapeutics companies. That’s because consumers who are actively seeking solutions and paying out-of-pocket are intrinsically more motivated, and can accordingly achieve more success on average with behavioral treatments. The opportunity lies with entrepreneurs to create compelling solutions that give this highly activated audience what they want and need.

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Thanks to Ella Chiang and RJ Ellis for input on this post.