hear the phrase "digital health," we might think
about our Fitbit, the healthy eating app on our smartphone, or
maybe a new way to email our doctor.
Fitbits aren’t particularly useful if you’re homeless, and
the nutrition app won’t mean much to someone who struggles
to pay for groceries. Same for emailing your doctor if you don’t
have a doctor or reliable internet access.
is a disconnect between the problems of those who need the
most help and the tech solutions they are being offered,"
said Veenu Aulakh, executive director of the Center for Care
Innovations, an Oakland, Calif.-based nonprofit that works to
improve health care for underserved patients.
digital health "pitchfests," it’s pretty much
white millennials hawking their technology to potential
about the shiny new object that really is targeted at solving
problems for wealthy individuals, the ‘quantified-self’
people who already track their health," Aulakh said.
"Yet … what if we could harness the energy of the
larger innovation sector for some of these really critical
issues facing vulnerable populations in this country?"
but growing effort is underway to do just that. It’s aimed
at using digital technologies — particularly cellphones —
to improve the health of Americans who live on the margins.
They may be poor, homeless or have trouble getting or paying
for medical care even when they have insurance.
initiatives are gaining traction partly because of the growing
use of mobile phones, particularly by lower-income people who
may have little other access to the internet.
Affordable Care Act and the expansion of Medicaid have added
millions of previously uninsured people to the nation’s
health care system, including community health clinics that
serve poor and largely minority populations, according to a
California Health Care Foundation report. (California
Healthline is an editorially independent publication of the
California Health Care Foundation).
California alone, the number of people on Medi-Cal, the state’s
version of the Medicaid program for the poor, rose from 7.5
million in 2010 to 12.4 million by early 2015. Many Americans
remain uninsured, however, because they live in states that
have declined to expand Medicaid eligibility.
advocates say it’s important to tailor digital health
technologies to lower-income people not only to be fair, but
because they’re more likely to have chronic illnesses, like
diabetes, that are expensive to treat.
providers have incentives as well. They are being rewarded
financially under the Affordable Care Act, Medicare and
Medicaid for keeping patients healthy, and this goes beyond
simply performing medical procedures and prescribing drugs.
experiments targeting low-income people are a tiny part of the
digital health industry, which racked up an estimated $4.5
billion in venture funding in 2015 alone. Entrepreneurs are
still trying to figure out how they’re going to get paid by
serving this population, and government health programs like
Medicaid and Medicare are taking a while to figure out how
they’re going to pay providers for approaches that don’t
involve a doctor visit.
Sarasohn-Kahn, author of the California Health Care Foundation
report, says investors are getting more interested in digital
health initiatives for low-income patients simply because
there are so many of them.
are eyeing the "fortune at the bottom of the
pyramid," she said, much as Walmart profits from selling
low-priced items to millions.
now sexy to scale," she says. "If you can have
impact (on many people), inexpensively, you can make a lot of
money. If we get it right, we can do well and do good."
initiatives are simple and cheap, like Text4Baby. The free
text-messaging service for pregnant women and new moms offers
English- and Spanish-language information about prenatal care,
labor and delivery, breastfeeding, developmental milestones,
and immunizations — all timed to the baby’s due date.
by the nonprofit ZERO TO THREE and the mobile health company
Voxiva, Inc., Text4Baby has reached nearly 1 million women
since starting in 2010. In one survey, more than half of them
reported yearly incomes of less than $16,000.
experiments are far more elaborate. In California and
Washington state, San Francisco-based Omada Health is testing
a version of Prevent, a diabetes and heart disease prevention
program that’s been modified for "underserved"
populations — basically people on Medicaid or who are
uninsured. The free program offers patients a digital scale as
well as behavior counseling and education, access to a
personal health coach and an online peer network.
the program, the company made it available in Spanish and
English and lowered its reading level from ninth grade to
fifth grade. Bilingual health coaches were hired, and the
educational materials now acknowledge potential food access,
neighborhood safety and economic issues that participants may
face, said Eliza Gibson, Omada’s director of Medicaid and
safety-net commercial development.
scale doesn’t require a wireless connection, and the patient
just needs to be able to access the internet for one hour each
week, Gibson said.
enrolling 300 community clinic patients in Southern California
and rural Washington in a year-long clinical trial of Prevent,
in hopes that the program can demonstrably slow the progress
at other community clinics in California will try out the
program but won’t be included in the clinical trial, Gibson
said. Omada Health is also offering a version called Prevent
for Underserved Populations that specifically targets
low-income community clinic patients.
the people trying out the program is Susy Navarro, an
elementary school substitute teacher who lives in the Spring
Valley community east of San Diego. After being diagnosed with
prediabetes, Navarro, 28, set an ambitious goal to lose 100
pounds. In the meantime, she is taking medication to stave off
Type 2 diabetes.
name it, I’ve probably tried it — Weight Watchers,
low-fat, low carb, pills, injections, acupuncture,"
Navarro said. "The first time I try things it goes very
well, I feel like I’m very successful, then I wean off and I’m
not successful. This program focuses more on life choices that
are going to help us out long-term, not just for a little
described the scale she was given as "sophisticated
looking — all black, flat, digital." It has been
programmed to her weight profile — she is considered obese
— and transmits her weight every morning to the program’s
program, with its daily weigh-ins, helps her pay attention to
what she eats, and her blood sugar levels are declining,
Navarro said. She also appreciates the ability to connect
online with fellow patients on her "team." "It’s
very awesome — you get to know the other members and feel
like it’s a team effort."
continue to explore digital health possibilities for
underserved patients, developers are learning more about what
works and what doesn’t, says Sarasohn-Kahn. For example,
apps chew up a lot of cellphone data, so many community clinic
patients prefer lower-cost text messaging.
Petaluma Health Center, a network of community clinics in
Sonoma County, Calif., staffers offered free, simplified
"loaner" digital devices to patients after a
hospital stay to help them avoid complications that could land
them back in the hospital.
first offered an Android tablet to allow for a video visit
with a health professional, but patients were reluctant to
take it, saying it was hard to hide and could be stolen, said
Dr. Danielle Oryn, the network’s chief medical informatics
they tried iPhones, in which everything was locked down except
the ability to call 911 and a single button triggering the
video visit. Those were more acceptable. Still, there were
challenges. Would patients, some recuperating at homeless
shelters, have access to electricity to charge their phones?
Oryn said they had to learn by trial and error. She was
surprised and pleased to see seniors accepting the technology.
Every loaner iPhone was returned to the clinic.
advice to the captains of the digital health industry?
should "not necessarily come in with too many
assumptions. They should come with an open mind and a
willingness to listen," Oryn said. "Safety-net
people are very excited to have these companies interested in
them and to share their experiences."