The role of health-care providers in mHealth adoption
Authors: Simon Leigh, Liz Ashall-Payne
Journal: The Lancet Digital Health (2019)

Health-care providers, the gate keepers of health-care delivery, are important but understudied stakeholders in integrating digital health technologies (DHTs) into routine clinical practice. A doctor's recommendation goes a long way in encouraging patients to use DHTs, and research increasingly suggests that a desire for DHTs exists among health-care providers.1Albrecht UV Afshar K Illiger K et al.Expectancy, usage and acceptance by general practitioners and patients: exploratory results from a study in the German outpatient sector.Digit Health. 2017; 3 (2055207617695135)PubMed Google Scholar, 2Kessel KA Vogel MM Schmidt-Graf F et al.Mobile apps in oncology: a survey on health care professionals' attitude toward telemedicine, mHealth, and oncological apps.J Med Internet Res. 2016; 18: e312Crossref PubMed Scopus (35) Google Scholar, 3Berkowitz CM Zullig LL Koontz BF Smith SK Prescribing an app? Oncology providers' views on mobile health apps for cancer care.JCO Clin Cancer Inform. 2017; 1: 1-7Crossref PubMed Scopus (26) Google Scholar However, despite recent policy recommendations advocating the use of health apps in routine clinical practice,4Bernal N GPs urged to 'prescribe' apps to over 50s to tackle Britain's loneliness epidemic. The Telegraph.https://www.telegraph.co.uk/technology/2019/03/20/gps-urged-prescribe-apps-50s-tackle-britains-loneliness-epidemic/Date: 2019Date accessed: April 6, 2019Google Scholar, 5Torous J Andersson G Bertagnoli A et al.Towards a consensus around standards for smartphone apps and digital mental health.World Psychiatry. 2019; 18: 97Crossref PubMed Scopus (163) Google Scholar and publication of the National Institute for Health and Care Excellence (NICE) evidence framework for DHTs,6National Institute for Health and Care ExcellenceEvidence Standards Framework for Digital Health Technologies.https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/evidence-standards-framework/digital-evidence-standards-framework.pdfDate: March, 2019Date accessed: April 6, 2019Google Scholar such technologies are rarely recommended by health-care providers in practice. We interviewed groups of digital health experts, practice nurses, allied health professionals, secondary care doctors, and general practitioners to determine the factors important to health-care providers for considering the recommendation of DHTs to patients. Combined with a pragmatic literature review, we identified nine factors which might affect digital decision making among health-care providers (table). From Feb 18, 2019, to April 1, 2019, we invited health-care providers from the UK to take part in a short survey (appendix), either online or via paper forms to identify factors instrumental in health-care providers advocating DHTs to patients. We invited 30 health-care providers in person, of which 28 agreed to take part (93% participation rate), with a further 57 accessing the survey online following advertisement via social media, which resulted in 85 responses in total. All respondents were based in the UK. A job title was collected for 60 (71%) of the 85 respondents; 25 did not answer the question. Among the individuals who answered, 24 (40%) were nurses, 17 (28%) were allied health professionals (such as speech and language therapists), 13 (22%) were general practitioners, 3 (5%) were secondary care doctors, and 3 (5%) answered "other". An ordinal scale design was applied, where participants ranked themes from 1 (most important) to 9 (least important). Tests for statistical significance were done using the Kruskal-Wallis H test, followed by a post-hoc Dunn's test when significant differences, defined at the conventional level of 5% (p<0·05), were identified (appendix).TableSurvey questions and rank scores for attributesMean (SD)Median (IQR)ModeStamp of approval from MHRA, NHS, or other accrediting body3·5 (2·55)3 (1–5)1Published studies to demonstrate safety or effectiveness3·7 (2·45)3 (1–6)1The DHT has been recommended by other health-care providers4·8 (2·48)5 (3–7)8You have personally used the DHT4·9 (2·40)5 (3–7)5Cost5·1 (2·51)5 (3–7)2The DHT has been created by other health-care providers or clinical bodies5·2 (2·33)5 (4–7)4Having appropriate IT to trial and demonstrate DHT to patients5·6 (2·37)6 (4–8)7Unmet need within the condition experienced by the presenting patient5·8 (2·71)6 (4–9)9The DHT is easy to prescribe (included in EMIS Web or SystmOne)6·1 (2·09)6 (5–8)8Participants were asked to rank attributes from 1 (most important) to 9 (least important). MHRA= Medicines and Healthcare products Regulatory Agency. NHS=National Health Service. DHT=digital health technology. IT=information technology. Open table in a new tab Participants were asked to rank attributes from 1 (most important) to 9 (least important). MHRA= Medicines and Healthcare products Regulatory Agency. NHS=National Health Service. DHT=digital health technology. IT=information technology. Our results (appendix; table) suggested that health-care providers were most concerned about DHTs having a stamp of approval, whether from the National Health Service (NHS), Medicines and Healthcare products Regulatory Agency (MHRA), or otherwise (table), which received a statistically significantly higher ranking for all attributes except the presence of published studies of safety or clinical effectiveness. The presence of published studies was also valued significantly greater than all other attributes, except for a stamp of approval. Having personally used a DHT previously and receiving recommendations from other health-care providers were also of some importance to health-care providers, both of which were statistically significantly more important than making DHTs easier to prescribe to patients, such as including them within EMIS Web or SystmOne. The cost of the DHT, whether it was created by health-care providers, the level of unmet need in the condition under consideration, having access to appropriate technology to demonstrate DHTs to patients, and ensuring apps are easy to prescribe did not result in a difference in preferences among health-care providers. For an innovation to be adopted throughout the whole NHS takes approximately 17 years,7National Health ServiceNHS Innovation Accelerator Programme.http://healthinnovationnetwork.com/system/resources/resources/000/000/171/original/A5_Launch_brochure.pdfDate: 2017Date accessed: April 6, 2019Google Scholar and the NHS's travails with introducing new technology are well documented. However, the promise of DHTs has never been so pronounced as it is now. For the first time, the evidentiary expectations of DHTs are objective, transparent, and proportionate; with a roadmap to inclusion on the NHS Apps Library, catalogues of safe and effective DHTs made available to the public through the Organisation for the Review of Care and Health Applications (ORCHA),1Albrecht UV Afshar K Illiger K et al.Expectancy, usage and acceptance by general practitioners and patients: exploratory results from a study in the German outpatient sector.Digit Health. 2017; 3 (2055207617695135)PubMed Google Scholar and policy-makers now actively endorsing the digital health agenda.4Bernal N GPs urged to 'prescribe' apps to over 50s to tackle Britain's loneliness epidemic. The Telegraph.https://www.telegraph.co.uk/technology/2019/03/20/gps-urged-prescribe-apps-50s-tackle-britains-loneliness-epidemic/Date: 2019Date accessed: April 6, 2019Google Scholar, 5Torous J Andersson G Bertagnoli A et al.Towards a consensus around standards for smartphone apps and digital mental health.World Psychiatry. 2019; 18: 97Crossref PubMed Scopus (163) Google Scholar What health-care systems are still struggling with, however, is encouraging health-care providers to become advocates of digital health, to trust DHTs, and to have confidence in recommending these technologies to patients who might not be fully benefiting from traditional health services. The survey responses we have collected show that health-care providers have several concerns, which must be assuaged before digital medicine can move from theory into clinical routine. Chief among these concerns are assurances regarding safety and clinical effectiveness, and DHTs having a NICE, NHS, or MHRA stamp of approval—both of which have been mirrored in previous research.8Van Mierlo T Fournier R Fedorak R Don't forget the doctor: gastroenterologists' preferences on the development of mHealth tools for inflammatory bowel disease.JMIR Mhealth Uhealth. 2015; 3: e5Crossref PubMed Scopus (13) Google Scholar Although obtaining evidence of effectiveness has historically been an insurmountable task to most app developers, NICE's proportionate evidence standards framework has asserted that not all apps are equal and that one size does not fit all.6National Institute for Health and Care ExcellenceEvidence Standards Framework for Digital Health Technologies.https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/evidence-standards-framework/digital-evidence-standards-framework.pdfDate: March, 2019Date accessed: April 6, 2019Google Scholar mHealth randomised controlled trials (RCTs) are now not the only method available for evaluating DHTs.6National Institute for Health and Care ExcellenceEvidence Standards Framework for Digital Health Technologies.https://www.nice.org.uk/Media/Default/About/what-we-do/our-programmes/evidence-standards-framework/digital-evidence-standards-framework.pdfDate: March, 2019Date accessed: April 6, 2019Google Scholar, 9Greaves F Joshi I Campbell M Roberts S Patel N Powell J What is an appropriate level of evidence for a digital health intervention?.Lancet. 2019; 392: 2665-2667Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 10Nicholas J Boydell K Christensen H mHealth in psychiatry: time for methodological change.Evid Based Ment Health. 2016; 19: 33-34Crossref PubMed Scopus (20) Google Scholar This progress raises the possibility of high-quality, safe, and clinically beneficial DHTs—which perhaps historically did not benefit from the funding or support necessary to undergo traditional evaluation by means of an RCT—now benefiting from an equal opportunity for fair and proportionate evaluation, where the app that teaches yoga is not under the same level of technical scrutiny as the app used to calculate insulin doses. As incumbent assessment processes, such as the NHS Digital Assessment Questions, begin to incorporate proportionate evidentiary requirements (such as those provided by NICE), stamps of approval from notified and credible bodies should increase. However, so too could the burden of data review, and additional workload for prescribers, following the use of DHTs, which might affect the types of DHTs health-care providers recommend, at least initially. This development should provide valuable reassurance to cautious and digitally hesitant health-care providers that greater numbers of DHTs are credible, up to date, and provide accurate information. However, pivotal to this process is ensuring that this notion of not all apps being equal is accepted by health-care providers who have the ultimate responsibility for patient wellbeing. Trusted advocates of digital health such as ORCHA, NHS Digital, and NICE have a substantial role in this process, specifically in ensuring that: health-care providers are well informed of the benefits that digital health can deliver; know how and where to access DHTs that have been proven to be effective; are aware of what level of evidence is appropriate for each kind of DHT available; and that health-care systems understand the current barriers and facilitators to the implementation of digital health among this crucial but understudied stakeholder group. Only by building on these simple foundations of accreditation, evidence, and awareness, and providing health-care providers with the reassurances they require to be confident that they are first doing no harm, will it become possible to close the digital prescribing loop between patients desiring DHTs, regulators and notified bodies assessing them, policy makers recommending their use, and patients being offered clinically beneficial, safe, and trusted digital technologies by the health-care providers that they trust. Neither SL or LA-P have ever personally received funding of any means (teaching, research, or advisory) from any company or individual with an interest in the creation or sale of digital health technologies. Both SL and LA-P are employed by the Organisation for the Review of Health and Care Applications, a specialist digital health company. Download .pdf (.33 MB) Help with pdf files Supplementary appendix