**2. The challenge**

Dr. Eric Topol, who many consider being the father of modern Digital Health, presents Artificial Intelligence as a solution to make Healthcare human again. In his book Deep Medicine, he describes how technology can do this but warns that it will be a "marathon without a finish line." He points out that this is mostly due to inadequacies of AI technology, both functionally and from the lack of evidencebased clinical outcomes [5]. This scarcity of proof is the main reason why healthcare decision-makers are reluctant to invest in the resources to evaluate and use new Digital Health technologies. Lim and colleagues did a survey of CEOs from startups regarding slow healthcare adopters to digital technology. All agreed that this was due to the asymmetric impact of regulatory pressures; that is, even if a Digital Health product met regulatory requirements, healthcare providers were reluctant to accept risk as there was no evidence to support outcomes. Another reason was the need for multidisciplinary buy-in from other stakeholders [6].

Cost issues due to prior investment and ongoing maintenance of existing technological applications likely play a role. Most organizations have not done reliable cost analysis studies. When we have looked at this informally within our national organization, retiring legacy applications that were not needed or not useful lead to substantial overall one-time and annual cost savings even with the added expense of new solutions.

To illustrate the current "standard" evaluation process, we want to share three examples of technology used in our practice. These are not unique as there are many similar scenarios in other healthcare systems. Video for direct patient care is spotlighted since the pandemic has pushed it to the forefront. We have had urgent care video visits for years. Still, our established platform was not easy to apply in specific case uses- poor connectivity in hospital and home, difficulties for the patient to create an account, benefit confirmation, and navigating the application. The offshoot has been superficial and informal evaluation then rapid implementation of many other video platforms. Well-intentioned champions lead these on a case-by-case needs basis, and none were adequately studied. The result is a host of video applications, multiple contracts, patient and clinician confusion and frustration over many duplicate tools. The "back up" applications (which some intentionally use as their primary ones) are meant for social media and not safe medical use. We have quadrupled the number of video applications in our multispecialty group, and there does not appear to be an end in sight. The approach is straightforward: solve the problem in isolation, and no matter what device is needed, get it, and put it into production.

Another example centers on getting more value out of video visits. These typically do not include vital signs, exam modalities, and post-visit testing like a laboratory. We have an in-house kit that has been used for years to do remote patient monitoring on chronic patients like those with congestive heart failure. It contains blue-tooth enabled tools and a phone-linked tablet. The patient takes their blood pressure, weight, oxygen saturation, pulse, and temperature, with results automatically uploaded from the tablet to the company's web dashboard. We have modified it to meet our episodic need for vital signs before a scheduled video visit or to follow labile patients like those with uncontrolled hypertension over a few days. The patient can efficiently perform self-directed vital signs, uploaded to the provider's Medical Assistant, who then transcribes the data to the patient's EMR. A phone call then connects the patient at the pre-arranged time for the kit's video visit.

Concurrently, two other tablet devices are being tested by our national provider organization even though the first tablet with the Blue-tooth enabled vital signs tools appears much easier for the patient and physician to use. These other two do not have Bluetooth-enabled vital signs tools, so manual ones are delivered simultaneously as the tablet. We are currently comparing the three devices, but this is not being done in a formal, systematic way. An important point here is that the delivery means and organizational process, cleaning, and repacking are similar no matter the device used. The cost of the tool and how it performs are the main differentiators. Of course, politics too. One of our sister care delivery organizations has seen excellent results using one of these devices in engaging seniors at home and at the curbside, which has led to significant gap closure of population health measures. An outside vendor is offering this one. The other two belong to our company, which means a financial impetus to develop new case uses.

Another company's video option is the cheapest via a supplemental monthly physician subscription fee, easiest to scale, and already shown to work well. We have used their core function of texting between providers for years. They quickly developed secure, compliant, and high-quality connectivity to patients via texting and audiovisual, which allowed many case uses, including visits with patients in Skilled Nursing Facilities (SNIFs), home, and the curbside. It is as simple as texting the patient with an invitation to connect for an audiovisual visit on their smartphone or other connected devices. Naysayers question whether or not patients have access to their own devices capable of reliable audiovisual connectivity. Our surgical centers have been using this and have found that 75% of seniors have reliable personal mobile phones. We are still piloting three tablets, which are more expensive, not as easy to use, and possibly not scalable.

Our care delivery organization has had an Electronic Medical Record (EMR) program for nearly 20 years. With the overall goal of improving communication between patients and colleagues, we have contracted with the EMR vendor to add other components of a patient management solution- a patient portal, a program for scheduling, and video and texting applications. Another national vendor has the video platform that we have used for many years. It, too, is quickly adding other communication modes- texting and a stand-alone mobile video application. While both vendors appear to have solutions for comprehensive virtual care and communication, we have not been afforded the chance to test them. There also have been limited learnings from real clinical settings. Much of the vendors' offerings are still being developed. Even if a preliminary look is optimistic, we will have to spend time and money on further development and testing to end up with a final customized tool.

We recently started a pilot looking at a third option. A global tech company has a comprehensive communication tool that is easy to use, inexpensive, and customizable. We are looking to see if it can streamline connectivity between clinicians and staff, improve patients' experience doing video visits and scheduling, and allow easy connection to patients in the community. For example, hospitalized patients

#### *Emerging from Smoke and Mirrors DOI: http://dx.doi.org/10.5772/intechopen.96212*

need a discharge "navigator" to coordinate care and follow-up and better medication adherence through real-time reconciliation to reduce Emergency Department visits and re-admissions. We are facing two stumbling blocks with testing- lack of access to the full functionality of the software and no workforce dedicated to conducting most pilot components.

What drives a tool's incorporation into a trial or pilot? It should always begin with a clinical or health care need or problem, or a case use that a technological tool or solution can help. Next, the device must meet all "Availability Criteria"- technologically sound- meaning that it works the way it professes to, is easy to use, is scalable, is customizable, and is affordable. Now it could move on to the pilot step for testing in a live environment. These examples of devices have not met the necessary criteria but are in pilots or have already been put into use.

Subjective business decisions made in isolation are often the culprit. The goal of getting to one EMR across many provider groups is appropriate. However, technology leadership is singularly focused on this directive and not properly vetting the vendor's ability to deliver and support the tool's capabilities, functionality, and need for development. Deadlines are missed, and costs are exceeded. Still, worst of all, the solution may never get to intended production.

We have many corporate leadership examples, seeing "the next best thing to come in Digital Health." A tool is quickly given capital support from the company or is acquired. Advocates demand quick implementation of the device. Often, it has no explicit end-user use, has not passed the five Availability Criteria, nor has it been shown to improve outcomes in formal pilots.

We see this coming from many other non-clinical divisions. The marketers who have historically been given Digital Health leadership roles love tools to enhance patient experience via the internet. The technology leaders find or create tools that they can solve problems with from their technological perspective. Neither group engages much with clinicians to determine their initiatives' implications on patients, providers, care, and outcomes.

So, we do not have an excellent way to evaluate the technology. Validation requires that we study the technology and potential outcomes. First, though, a problem is identified as the reason for trying out the technological solution.

Case uses can be about a specific problem or very broad. They can be for clinical or non-clinical. Short-term or long-term. Patient-specific or physician-specific. Provider System or Payer. It is easy to add in others. **Table 1** illustrates some examples. These case uses should be compatible with the vision and strategic goals of Digital Health and the overall organization.


#### **Table 1.**

*Examples of end-use requirements or case uses.*
