Background
As Daniel Kraft so eloquently imparted in his keynote speech at the 2019 annual Alliance conference, digital health technologies are already changing healthcare. Digital health is an umbrella term for technologies that include electronic health records (EHRs), social media tools, mobile apps, wearable devices, telemedicine and more. These technologies are designed to generate considerable real-time patient- or provider-generated data, to enable focused care for the individual patient via real-time analytics and feedback, or to guide population-level care based on aggregate patient-reported clinical and outcomes data. Consumer surveys (e.g., Rockville; Pew Research) show high rates of digital health adoption among patients and health consumers (especially for accessing online health information) and growing use of mobile technologies. There existed over 250,000 mHealth apps alone in 2016 (Medium.com, 2017), many with the potential to help patients track symptoms, monitor progress, improve medication adherence, connect with other patients or other potential benefits that could make patient care more personalized while reducing healthcare costs, improving access to care, or streamlining inefficiencies.1 Similarly, many physicians already are using mobile devices to access patient data, communicate with other healthcare providers (HCPs) and access decision support or other business intelligence applications.2 By 2022, market forecasting anticipates that 90 percent of clinicians will use point-of-care mobile devices.3 Accordingly, the United States Food and Drug Administration has launched a Digital Health Innovation Action Plan to address the role of digital health technologies,4 and several randomized clinical trials are ongoing to investigate the feasibility and impact of digital health technologies on disease management (e.g., in diabetes, asthma and mental health) and performance indicator improvement (e.g., hospital readmission).5 

However, the profusion of digital health tools, including EHR, can lead to confusion among providers, information overload, alert fatigue and frustration with the lack of interoperability among systems. For instance, while Kardiaband, a personal electrocardiogram (EKG) device that can be used directly with the Apple Watch, can provide real-time EKG data, physicians are often overwhelmed with longitudinal information about patient heart rhythm and rate that they are unable—and seldom inclined—to act on it.6 At the same time, existing data on the effectiveness of digital health tools to improve patient or population health outcomes varies in credibility and reliability.7 

Education and Digital Health
Despite these potential barriers to digital health adoption, providers will need to become adept at using digital health in clinical practice. Concomitantly, the field of continuing professional development will need to become proficient in educating providers on how to integrate patient-facing digital health tools into treatment planning as well as to effectively utilize digital health technologies in clinical decision-making. However, experience of incorporating digital health into CPD activities remains limited and the depth of awareness and knowledge of how to integrate digital health tools into CPD activities is not well documented. Accordingly, in 2018, the Alliance Research Committee fielded a survey to assess current attitudes, knowledge and experience with digital health among members of the Alliance for Continuing Education in the Health Professions (ACEHP).

ACEHP Survey
The committee developed a brief, nine-question survey that was fielded via email to approximately 2,330 ACEHP members. The response rate of 9 percent yielded 211 responses across Alliance member sections (Figure 1).

Figure 1. Survey Respondents

Beyond personal digital devices, familiarity with different digital health devices was relatively low (Figure 2). 

Figure 2. Familiarity with Digital Health Technologies

Over half (62 percent) of respondents had experience of using digital health devices to monitor or manage a personal health condition, and 50 percent reported professional experience of integrating digital health tools into educational activities. Attitudes to the role of medical education integrating digital health were mixed (Figure 3).
 

Figure 3. Attitudes to Digital Health

However, additional analysis of reported professional experience in integrating digital health to educational activities suggested latent confusion about what digital health is and how it can be used in education. For instance, more than half of respondents reporting professional use of digital health tools described using education delivery platforms and tools (e.g., smartphone audience response systems) versus content about clinician use of digital health tools in the direct care of patients.

In addition to descriptive statistical analysis, qualitative analysis of open-ended responses to survey questions identified several themes and unresolved questions about digital health (Figure 4). Specifically, we asked, “What questions do you have about Digital Health or the role of CME in Digital Health?” A sampling of responses follows:

• “Is CME prepared to address the integration of digital health into standard healthcare situations, ie, does the profession have the expertise to address?”
• “Need more education regarding legal ramifications for use as it evolves.”
• “How to train clinicians to use before rollout so it does not detract from the education”
• “What is the incentive for the HCP to incorporate these tools into their practice? I have seen more of the benefit to the patient and making the patient more engaged.”
• “What resources can CPD providers leverage to do this? How can smaller CPD offices accomplish something like this?”
• “Perceptions around privacy and uptake with digital health especially in the baby boomer population should be addressed.”
• “We need recommendations on how to not only incorporate usage, but an understanding of how to educate physicians on how to teach their ‘resistors’ to embrace technology that could help them.” 
• “What's the low hanging fruit? Where do we start? I'd like to succeed with our initial intervention.”
• “How can we help physicians integrate digital health solutions into their clinical practices without creating additional burden?”

Figure 4. Unresolved Questions about Digital Health

 
These qualitative themes suggest that CPD professionals feel under-informed about digital health and seek additional exposure to information about digital health, especially in relation to privacy and data access concerns. CPD professionals also are concerned about the funding costs of supporting education that addresses digital health and unclear about the current evidence base to support digital health, which many feel is still in its infancy. Finally, CPD professionals seek clarity on patient perspectives regarding digital health. 

Discussion
This survey shows diffidence and lack of knowledge among Alliance members about the scope and role of digital health technologies in CPD education activities. It is incumbent on the CPD field to educate its own members about digital health as a precursor to creating education for HCPs that uses and models how to integrate digital health to support chronic disease management and clinical decision-making. 
Examples of education activities to support such integration are emerging. For instance, there is evidence that digital health tools provided as part of CPD—prescribed patient support and education—can improve outcomes in patients with psoriasis. A CPD educational initiative on psoriasis offered three months of digital health coaching to the patients of dermatologists who participated in the educational activity. Patient-reported outcomes from the initiative demonstrated improvements in clinical and behavioral outcomes from baseline for patients with psoriasis in the intervention arm.8 

Conclusion
Education for patients could be deployed effectively to support the integration of digital health interventions to chronic disease management. Similarly, education for providers will be essential to ensure they are equipped to function in the integrated care environments that characterize many healthcare systems. The field of CPD is potentially poised to support HCPs to adopt digital health and integrate digital health tools in clinical decision-making and patient care. However, CPD professionals themselves are in need of foundational knowledge and skills to build their capacity for education in this area. 

References

1. Greis C, Zürcher CM, Djamei V, et al. Unmet digital health service needs in dermatology patients. J Dermatolog Treat. 2018 Nov;29(7):643-647
2. Convergence of mobile technology and the healthcare industry. Available at: https://www.rapidvaluesolutions.com/convergence-of-mobile-technology-and-the-healthcare-industry/
3. Landi H. Study: 9 in 10 clinicians to use mobile devices by bedside by 2022. Available at:  https://www.healthcare-informatics.com/news-item/mobile/study-9-10-clinicians-use-mobile-devices-bedside-2022
4. United States Food and Drug Administration. Digital Health Innovation Action Plan. Available at: https://www.fda.gov/downloads/medicaldevices/digitalhealth/ucm568735.pdf
5. clinicaltrials.gov. Clinical trials in digital health. Available at: https://clinicaltrials.gov/ct2/results?cond=&term=digital+health&cntry=&state=&city=&dist=
6. Wakabayashi D. Freed from the iPhone, the Apple watch finds a medical purpose. New York Times. Dec. 26, 2017
7. Kaufman N, Khurana I. Using digital health technology to prevent and treat diabetes. Diabetes Technol Ther. 2016; Suppl 1:S56-68
8. Reiter J, Perez J, Tordoff S, Faler W, Srivastava U. Presented at Fall Clinical Dermatology Conference-2017. October 12-15, 2017, Las Vegas, NV