By Dr Pritesh Mistry. Pritesh draws upon his experience leading innovation initiatives in primary and secondary care co-developing solutions with clinicians, researchers, industry and patients at St Thomas’ Hospital and Royal College of GPs to provide insights on innovation in healthcare. Read weekly articles on his blog here.
Software is expected to play a larger part in healthcare in the near future, documents such as the NHS Long Term Plan outline healthcare’s drive to embrace digital. The expectation is that greater use of digital will cut costs of healthcare delivery and expand access while increasing the flexibility and convenience of how care is accessed. Is this naive and does well established consumer behaviour set unrealistic expectations?
Proliferation of apps
One of the highly anticipated use cases for digital (e.g. apps and software) in health is the direct delivery of evidence based interventions, this aspect of digital health has been coined digital therapeutics. Apps are already being developed to provide medical interventions in mental health, substance use disorder, sleep deprivation, and other clinical areas.
The 2009 “there’s an app for that” marketing campaign by Apple has become a reality. It’s been ten years since the start of the campaign and we see and engage with apps everywhere. With this comes a set of experiences that set our expectations, these expectations are now being carried over into healthcare.
The quality of the apps we have become accustomed to are hugely variable, some apps are shells that function badly and are incapable of meeting basic expectations, where as others are fantastic and do exactly what we need. Reviews and ratings help users comb through this but when there’s money to be made we find reviews start being gamed and trust in the reviews becomes an issue. This experience makes us uncertain and skeptical on apps quality and effectiveness. In the UK healthcare domain the NHS Apps Library has an assessment process intended to provide a higher level of reassurance and avoid these issues.
App Stores have also seen a race to the bottom for app pricing. Software is largely seen as a commodity e.g. there’s a cost to create an app but the cost to replicate it is marginal and essentially free. Public perception of software is it is cheap and low cost and so as a result the public are often less willing to pay the same price for software as for a physical equivalent. This resulted in alternative app business models such as:
- Free to use monetised through selling user data and/or presenting adverts
- Freemium, where basic functionality is provided for free with in-app purchases to access premium features.
Our frequent engagement with App Stores sets our expectations on all apps. This creates an unrealistic set of expectations and is something we need to be mindful of as software interventions become more available in health. Such expectations have negative consequences and potentially holding back promising alternative treatment methodologies.
Perception versus reality
The perception and narrative of software as a low cost alternative medical intervention ignores the cost of developing an evidence based high quality reliable intervention.
Evidence generation through appropriate methodologies, regulatory approval, and quality assurance processes all take time and money. These are criteria we expect any medical interventions to adhere to and it’s no different for apps. However costs also need to be recuperated which will in turn increase the price of the app. This jars against our expectations and the rhetoric of software as a low cost alternative intervention methodology.
Differentiating between cost and value
Apps may not necessarily be cheaper intervention mechanism, we’ve had them on our phones for over ten years but in health it is a new paradigm and evidence generation methodologies are potentially less well established. Apps potentially provide an alternative to pharmaceutical drugs. However, many pharmaceutical drugs are generic, prescription costs per GP consultation are estimated as approximately £30 and 1 year’s treatment on antidepresents can cost as little as £13. This doesn’t compare favourably to digital therapeutics, and raises the questions: Will this incentivise companies to explore alternative funding models? Does the NHS Apps Library assessment process have strict enough restrictions to protect against misuse of potentially sensitive data or does it place too much onerous on the user?
Consumer access to software and apps have driven our expectations of them to be low cost commodities. For evidence based digital interventions to be accepted as an entirely new intervention mechanism needs a shift in expectations. Validated, quality assured software needs to be valued as a viable intervention mechanism and costed appropriately. Software as a cheaper intervention mechanism is a misconception that has the potential of holding back its implementation. With the narrative of digital providing a way to reduce healthcare spend and the reality being potentially quite different we risk simplifying the decision making to the one dimension of cost. However, there are benefits which are not found in medications such as no physical side effects, live measurement of efficacy for better informed intervention management, flexibility, convenience and no appointment scheduling restrictions.
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