Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping

The introduction of maximum reimbursement prices for digital health applications in Germany in 2022: Current developments

Germany serves as a pioneering example for the integration of digital health applications. Since October 2020, digital health applications that passed a benefit evaluation have been provisionally or permanently included in the benefit basket of the German statutory health insurance. However, free price setting by the manufacturers in the first year after the introduction in the benefit basket led to high prices. After several policy debates, maximum reimbursement prices were introduced. This article provides an overview of the changing reimbursement and pricing landscape after implementing maximum reimbursement prices. Processes of setting reimbursement prices are described, first results of maximum reimbursement prices are presented and critically reflected by views of stakeholders affected. Results of the first 1.5 years show that only four digital health applications were assigned a product-specific maximum price. For three of these digital health applications, the manufacturer's price is below the statutory health insurance's maximum reimbursement price. Although there is relatively minor impact on costs so far, this may change over the years with a growing number of digital health applications. Nevertheless, a systematic and transparent adjustment of the pricing mechanism after one year of inclusion in the benefit basket is necessary to strike a balance between the benefits of new digital health applications, statutory health insurance expenditures and the promotion of novel digital health applications.

Cuffless Blood Pressure Measurement Devices-International Perspectives on Accuracy and Clinical Use: A Narrative Review

Importance

Hypertension is a primary modifiable risk factor for cardiovascular death and disability. Accurate blood pressure (BP) measurement is essential for the diagnosis and treatment of hypertension. Conventional BP measurement with cuff devices is recommended but difficult for patients to perform due to inconvenience, discomfort, and challenges with appropriate cuff sizing and measurement protocols. The emergence of cuffless BP devices provides an opportunity to address many of these problems, including inconvenience, patient comfort, positional requirements, and continuous measurement.

Observations

Cuffless BP measurement devices are appealing to patients and clinicians, but validation of these technologies is essential before they can be deployed for clinical use. Key issues that remain include accuracy with risk of undertreatment or overtreatment, equitable access for low- and middle-income countries and minoritized populations, data privacy concerns, and how the devices will be deployed in clinical practice.

Conclusions

Clinicians and patients should only use validated BP cuff devices until cuffless BP measurement devices are appropriately tested and validated.

Compatibility of the CEN-ISO/TS 82304-2 Health App Assessment Framework With Catalan and Italian Health Authorities' Needs: Qualitative Interview Study

BACKGROUND

Health authorities of European Union (EU) member states are increasingly working to integrate quality health apps into their health care systems. Given the current lack of unified EU assessment criteria, the European Commission initiated Technical Specification (TS) CEN-ISO 82304-2:2021-Health and wellness apps-Quality and reliability (hereinafter the "TS") to address the scattered EU landscape of assessment frameworks (AFs) for health apps. The adoption of an AF, such as the TS, falls within member state competence and is considered an uncertainty-reduction process. Evaluations by peers as well as ensuring the compatibility of the TS with the needs of health authorities can reduce uncertainty and mediate harmonization.

OBJECTIVE

This study aims to examine the compatibility of the TS with the needs of Catalan and Italian health authorities.

METHODS

Semistructured interviews were conducted with key informants from a regional (Catalonia in Spain) and national (Italy) health authority, and a thematic analysis was carried out. Main themes were established deductively, following the aspects defined by the value proposition canvas: (1) health authorities' needs ("gains," "pains," and "jobs") and (2) the TS "products and services" and their distinct characteristics ("gain creators" and "pain relievers"). Subthemes were generated inductively. The compatibility of the needs with the TS was theoretically determined by the researchers. The results were visualized using the value proposition canvas. Two participant validation steps confirmed that the most relevant aspects of the predefined themes had been captured.

RESULTS

Despite the diversity of the 2 health authorities, subthemes were common and categorized into 9 gains, 9 pains, and 11 jobs. Key findings include the health authorities' perceived value of, and need for, integrating quality health apps and using an AF (gains), along with the related policy, implementation, and operational activities (jobs). The lack of enabling EU legislation and standardization, resulting in a need for the multiple authorities involved to consent, made achieving an AF challenging (pains). Nine products and services related to the TS and 17 distinct characteristics (eg, its multistakeholder evidence base) were found to be compatible with 3 gains (eg, stimulating the prescription and use of apps), 7 pains (eg, legislation and harmonization issues), and 6 jobs (eg, assessing apps). Indirect effects, 3 anticipated future services, and 1 anticipated gain creator and pain reliever increase this compatibility.

CONCLUSIONS

Our results suggest that the health authorities share common fundamental needs, and that the TS is compatible with these needs. The identified needs and compatibility can potentially reduce peer authorities' uncertainties in adopting an AF in general and the TS in particular. More research is recommended to confirm and translate our results in other contexts and further fine-tune compatibility to achieve wide adoption of the TS and accelerate the uptake of health apps.

Governance of research and product improvement studies in consumer mental health apps. Interviews with researchers and app developers

Consumer mental health apps (MHAs) collect and generate mental health-related data on their users, which can be leveraged for research and product improvement studies. Such studies are associated with ethical issues that may be difficult for researchers and app developers to assess. To improve ethical study conduct, governance through rules, agreements and customs could be relied upon, but their translation into practice is subject to barriers. This qualitative interview study with 17 researchers and app developers looked into the role and impact of governance standards on consumer MHA studies. Interviewees experienced a significant number of rules, agreements and customs, although not all of the governance standards that can potentially be applicable. Standards did have an impact on the interests of researchers and app developers, app users and society, but this impact was mediated by several barriers related to their conceptualization and implementation. Conceptualization barriers impacted the development of a standard, the inclusion of relevant concepts and the coordination between standards. Implementation barriers concerned the resource cost of understanding a standard, as well as suboptimal enforcement. The framework developed in this study can support more effective efforts to improve the governance of future consumer MHA studies.

Public value and digital health: The example of guiding values in the national digital health strategy of France

INTRODUCTION

In the WHO European Region, 44 of 53 reporting Member States (MS) have a national digital health strategy (NDHS) or policy. Their formulation is heterogenous and evolving and should best reflect public common interest. This research aims to explore how a public value approach improves the relevance of digital health policies and services, increasing their capacity to better serve the diverse range of societal interests. It utilises the guiding values within the French NDHS as an example before discussing other digital health policies such as the European Heath Data Space.

METHODS

Three homogenous focus group discussions were conducted in November and December 2023. Each focus group separately gathered distinct stakeholders: public clients, health professionals, private sector. 19 participants were included in the study. Data collection comprised live polling and semi-structured discussion. Results were analysed considering the pre-defined stakeholder groups and the values discussed during the study.

RESULTS

Findings reveal both technical and cultural challenges in digital health that highlight the need for adaptable frameworks across different contexts. Stakeholder insights informed a framework classifying public values into democratic and managerial categories, suggesting themes that may be relevant to digital health strategies in other national and regional settings.

DISCUSSION

Public value is discussed as a multidimensional concept, and the plurality of its perceptions give basis for tailored approaches to serve different value-beneficiaries comprehensively. We propose this values-based approach as a systematic model for supra-, sub-, and national scales and additional policy topics, beyond digital health strategies.

CONCLUSION

The study suggests that using a public value lens considering multiple perceptions is valuable for advancing digital health policy in a responsible and ethical manner. Such an approach could promote wider governance of and adoption of digital health. To evolve the framework, application in multiple and large ecosystems at different levels should be considered.

User journey method: a case study for improving digital intervention use measurement

BACKGROUND

Many digital mental health interventions meet low levels of use. However, current use measurement methods do not necessarily help identify which intervention elements are associated with dropout, despite this information potentially facilitating iterative intervention development. Here, we suggest improving the comprehensiveness of intervention use measurement with the user journey method, which evaluates every intervention element to identify intervention-specific use barriers.

METHODS

We applied user journey method in a clinical trial that investigated the efficacy of a novel game-based intervention, Meliora, for adult Major Depressive Disorder. We modelled the intervention for its four technological (Recruitment, Website, Questionnaires, Intervention Software) and two interpersonal elements (Assessment, Support). We then applied the user journey method to measure how many users proceeded from one element to the next combining social media analytics, website use data, signup data, clinical subject coordinator interview data, symptom questionnaire data, and behavioral intervention use data. These measurements were complemented with the qualitative analysis of the study discovery sources and email support contacts.

RESULTS

Recruitment: The intervention recruitment reached at least 145,000 Finns, with social media, word-of-mouth, and news and web sources being the most effective recruitment channels. Website: The study website received 16,243 visitors, which led to 1,007 sign-ups.

ASSESSMENT

895 participants were assessed and 735 were accepted. Intervention Software: 498 participants were assigned to the active intervention or comparator, of whom 457 used them at least once: on average, for 17.3 h (SD = 20.4 h) on 19.7 days (SD = 20.7 d) over a period of 38.9 days (SD = 31.2 d). The 28 intervention levels were associated with an average dropout rate of 2.6%, with two sections exhibiting an increase against this baseline. 150 participants met the minimum adherence goal of 24 h use. Questionnaires: 116 participants completed the post-intervention questionnaire.

SUPPORT

313 signed-up participants contacted the researchers via email.

CONCLUSION

The user journey method allowed for the comprehensive evaluation of the six intervention elements, and enabled identifying use barriers expediting iterative intervention development and implementation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05426265. Registered 28 June 2022, https://clinicaltrials.gov/ct2/show/NCT05426265 .

Impact of Rule 11 on the European Medical Software Landscape: Analysis of EUDAMED and Further Databases Three Years After MDR Implementation

Medicine is increasingly supported by software, with digital health technologies offering innovative ways to capture insights and drive therapies. Globally, medical device software must follow regulatory processes based on risk classification. The introduction of MDR represents a significant shift in risk-based classification for Medical Devices in Europe, including classification Rule 11 for software, which has caused significant discussions among European regulators. Three years after implementation, we conducted a systematic impact assessment of MDR classification Rule 11 for MDSW through a qualitative and quantitative analysis of over 2000 software entries from the European Medical Device database, complemented by data from other public databases such as the German DiGA directory and mHealthBELGIUM. Our results indicate that classification Rule 11 of the MDR results in a narrow bandwidth for class I software, whereas this used to be the most frequent classification for software under the MDD: while most of legacy software in EUDAMED falls in the lowest risk category as MDD Class I (53%), the situation reverses after the implementation of MDR with the most entries in Class IIa (55%). Analyzing the legacy MDD patient apps in Germany implies that three quarters will have to re-classify as MDR Class IIa at the end of the transition period in 2028. A comparison of the European and US regulatory landscapes, along with a systematic review of software features for Class I vs. Class IIa products, explains our findings and enables us to recommend a regulatory strategy for developing MDSW compliant with MDR Class I rules, ensuring fast access to the European market.

Healthcare professionals' attitudes towards digital health interventions and perspectives on digital health inequalities in cardiometabolic care: a qualitative study

BACKGROUND

The ue of digital health interventions (DHIs) for the management of cardiometabolic diseases has increased but may exacerbate existing health inequalities. Healthcare professionals (HCPs) play a vital role in recommending and supporting healthcare users to use these tools. There is a need to understand the role of HCPs in managing the implementation of digital health in communities at risk of health inequalities.

OBJECTIVE

To explore the views of HCPs regarding digital health and its impact on health inequalities, focusing on cardiometabolic diseases and the South Asian population in the UK.

DESIGN

We conducted online semi-structured interviews and focus groups with HCPs. These explored HCPs' experiences and attitudes towards digital health, their perceptions of healthcare users' barriers and facilitators to use such tools, as well as digital inequalities among specific healthcare user groups, and the impact of the COVID-19 pandemic on their practice in relation to digital health. After informed consent, transcription and coding, a reflexive thematic approach was taken for analysis.

SETTING

Primary, community and secondary care provided for cardiometabolic disease in the UK.

PARTICIPANTS

HCPs in general practice (n=3), cardiometabolic specialities (n=3), pharmacy (n=4) and other practices (n=8).

RESULTS

HCPs recognised the potential benefits of DHIs to improve access and delivery of care and healthcare user outcomes but described several barriers to successful implementation. HCPs demonstrated a good understanding of the challenges their healthcare users face in relation to wider inequalities, barriers to health behaviours and healthcare access, and digital health. Of particular concern was the impact of increasing reliance on digital interventions in healthcare on the exclusion of some population groups. Participants recommended improvement of the design and implementation of DHIs offered to healthcare users through working with at-risk populations throughout the process. Finally, participants emphasised the importance of ensuring non-digital services remained available to ensure equitable access to health and social care.

CONCLUSIONS

HCPs described the complexities of delivering care to underserved communities. DHIs were identified as a potential way to improve health outcomes for some, while over-reliance risked exacerbating inequalities. HCPs made recommendations related to design, implementation and engaging target populations and provided practical examples to address digital health inequalities, such as working with other sectors to take a community approach.

Prerequisites and Barriers to Telerehabilitation in Patients With Neurological Conditions: A Narrative Review

BackgroundA field of study that uses telerehabilitation (TR) is neurorehabilitation; however, standards for medical and technological applications, medicolegal and ethical regulations, and other aspects of neuro-TR are still being developed.ObjectiveTo address the prerequisites and barriers for implementing TR in neurorehabilitation in the light of present findings.MethodsA narrative review was conducted based on specific questions about the prerequisites for neuro-TR and barriers to its implication. According to a foreground search strategy in the context of neurorehabilitation using TR in neurological patient population, PubMed, EMBASE and Cochrane databases were searched and reviewed.ResultsBarriers and prerequisites for neuro-TR were mostly grouped under the categories of administrative/organizational, human (beneficiaries/providers), technical, and ethical. Apart from the technical framework, knowledge and the presence of an administrative leader responsible for overseeing TR are crucial prerequisites. The internet and technological constraints rank highest among the barriers.ConclusionSince neuro-TR is relatively new with minimal guidelines and regulations, highly technologic, and lack of established practices, it is imperative to determine and fully comprehend the criteria for its uses. After the prerequisites are established, it is imperative to recognize and address implementation constraints, which may differ depending on the community's infrastructure and neurologic condition.

A scoping review and expert consensus on digital determinants of health

Objective

To map how social, commercial, political and digital determinants of health have changed or emerged during the recent digital transformation of society and to identify priority areas for policy action.

Methods

We systematically searched MEDLINE, Embase and Web of Science on 24 September 2023, to identify eligible reviews published in 2018 and later. To ensure we included the most recent literature, we supplemented our review with non-systematic searches in PubMed® and Google Scholar, along with records identified by subject matter experts. Using thematic analysis, we clustered the extracted data into five societal domains affected by digitalization. The clustering also informed a novel framework, which the authors and contributors reviewed for comprehensiveness and accuracy. Using a two-round consensus process, we rated the identified determinants into high, moderate and low urgency for policy actions.

Findings

We identified 13 804 records, of which 204 met the inclusion criteria. A total of 127 health determinants were found to have emerged or changed during the digital transformation of society (37 digital, 33 social, 33 commercial and economic and 24 political determinants). Of these, 30 determinants (23.6%) were considered particularly urgent for policy action.

Conclusion

This review offers a comprehensive overview of health determinants across digital, social, commercial and economic, and political domains, highlighting how policy decisions, individual behaviours and broader factors influence health by digitalization. The findings deepen our understanding of how health outcomes manifest within a digital ecosystem and inform strategies for addressing the complex and evolving networks of health determinants.

Funding of digital health care for the management of chronic conditions in Australia

Digitally delivered health care, such as telehealth, mobile apps and remote monitoring via apps or devices, can result in improved outcomes for chronic conditions. However, Australia is struggling to maximise the potential of digital health for chronic conditions, due in part to funding arrangements that lack incentives for providers and end users. The aim of this article is to examine the current landscape of digital health funding for chronic conditions and considers potential funding arrangements for the future. Current funding arrangements for digital health in Australia lack sufficient incentives for both providers and end users, limiting the reach and effectiveness of digital health for managing chronic conditions. Alternative funding approaches, such as value-based models, are used internationally which include funding avenues for mobile apps and remote patient monitoring via apps or devices as well as for those operating digital health services. The development of sustainable value-based funding mechanisms that support stakeholder involvement and national adoption are recommended. For Australia to fully leverage the benefits of digital health in managing chronic conditions, funding reforms are one critical area to assist with the implementation of patient-centred and outcome-driven funding models. Effective and sustainable funding structures are essential to ensure long-term benefits of digital health for chronic disease management. Further research will be essential to identify effective funding avenues for digital health services, including mobile apps and remote patient monitoring.

Business Venturing in Regulated Markets-Taxonomy and Archetypes of Digital Health Business Models in the European Union: Mixed Methods Descriptive and Exploratory Study

BACKGROUND

Digital health technology (DHT) has the potential to revolutionize the health care industry by reducing costs and improving the quality of care in a sector that faces significant challenges. However, the health care industry is complex, involving numerous stakeholders, and subject to extensive regulation. Within the European Union, medical device regulations impose stringent requirements on various ventures. Concurrently, new reimbursement pathways are also being developed for DHTs. In this dynamic context, establishing a sustainable and innovative business model around DHTs is fundamental for their successful commercialization. However, there is a notable lack of structured understanding regarding the overarching business models within the digital health sector.

OBJECTIVE

This study aims to address this gap and identify key elements and configurations of business models for DHTs in the European Union, thereby establishing a structured understanding of the archetypal business models in use.

METHODS

The study was conducted in 2 phases. First, a business model taxonomy for DHTs was developed based on a systematic literature review, the analysis of 169 European real-world business models, and qualitative evaluation through 13 expert interviews. Subsequently, a 2-step clustering analysis was conducted on the 169 DHT business models to identify distinct business model archetypes.

RESULTS

The developed taxonomy of DHT business models revealed 11 central dimensions organized into 4 meta-dimensions. Each dimension comprises 2 to 9 characteristics capturing relevant aspects of DHT business models. In addition, 6 archetypes of DHT business models were identified: administration and communication supporter (A1), insurer-to-consumer digital therapeutics and care (A2), diagnostic and treatment enabler (A3), professional monitoring platforms (A4), clinical research and solution accelerators (A5), and direct-to-consumer wellness and lifestyle (A6).

CONCLUSIONS

The findings highlight the critical elements constituting business models in the DHT domain, emphasizing the substantial impact of medical device regulations and revenue models, which often involve reimbursement from stakeholders such as health insurers. Three drivers contributing to DHT business model innovation were identified: direct targeting of patients and private individuals, use of artificial intelligence as an enabler, and development of DHT-specific reimbursement pathways. The study also uncovered surprising business model patterns, including shifts between regulated medical devices and unregulated research applications, as well as wellness and lifestyle solutions. This research enriches the understanding of business models in digital health, offering valuable insights for researchers and digital health entrepreneurs.

Effectiveness of digital health applications on the quality of life in patients with overweight or obesity: a systematic review

BACKGROUND

Globally, more than half of the adult population is overweight, including those who are obese, which increases the risk of premature death and reduces quality of life (QoL). Technologies such as digital health applications (DiHA) can potentially improve clinical outcomes (e.g., health status, illness duration, QoL) or patient-related factors (e.g., therapy monitoring, adherence, health literacy). To date, there is no systematic review addressing the effectiveness of DiHA on the QoL in patients with overweight or obesity.

OBJECTIVE

The objective was to investigate the impact of DiHA on QoL in overweight or obese patients.

METHODS

A systematic literature search was conducted in MEDLINE via PubMed, Cochrane Library, and Embase via Ovid in 2023, supplemented by additional manual searches. The eligibility criteria included patients with overweight and/or obesity who used a digital intervention independently and without interaction with a healthcare professional. The outcome of interest was QoL. As potentially eligible trials had to demonstrate effectiveness, only randomized controlled trials (RCT) were included as the minimum evidence standard. The study screening (title-abstract, full-text) was conducted independently by two researchers using pre-specified eligibility criteria. CONSORT-EHEALTH checklist was used for data extraction of qualitative and quantitative data (study characteristics and study results) and the Cochrane Risk of Bias Tool (version 2) for quality assessment independently by two researchers.

RESULTS

Seven RCT conducted in Europe and the United States were included in this systematic review with a total sample size of N = 946. Observation periods were heterogeneous and ranged from 3 to 24 months. The evaluated interventions consisted of websites or apps, all of which included nutrition and physical activity features, and functioned independently with minimal or no involvement of a healthcare professional. All studies showed a high risk of bias, no statistically significant improvement and no effects regarding QoL using different validated questionnaires.

CONCLUSIONS

This systematic review provides a comprehensive analysis of DiHA effectiveness on QoL in patients with overweight or obesity. Overall, there is heterogeneity regarding the operationalization of QoL and the examined interventions have no statistically significant impact on QoL. Comparable systematic reviews show that digital interventions have the potential to improve the QoL of these patients, but further RCT and high-quality studies are needed to assess the impact of DiHA on QoL.

TRIAL REGISTRATION

PROSPERO CRD42023408994.

Transforming dementia research into practice: a multiple case study of academic research utilization strategies in Dutch Alzheimer Centres

BACKGROUND

Non-pharmacological dementia research products, such as social and behavioural interventions, are generated in traditional university settings. These often experience challenges to impact practices that they were developed for. The Netherlands established five specialized academic health science centres, referred to as Alzheimer Centres, to structurally coordinate and facilitate the utilization of dementia research knowledge. This study leverages implementation science to systematically explore the research utilization strategies used by academic researchers from each Alzheimer Centre, on the basis of the "knowledge-to-action" (KTA) framework that includes knowledge creation, adaptation, dissemination and implementation.

METHODS

Individual semi-structured qualitative interviews were conducted with 29 respondents across the five Alzheimer Centres in the Netherlands. Participants were selected through purposive (snowball) sampling. Interviews were conducted in-person and virtually through Microsoft Teams, and all were audio-recorded and transcribed verbatim. Data analysis was guided by the dimensions of the KTA framework.

RESULT

There was a high variation in the strategies used across the five Alzheimer Centres to bring non-pharmacological dementia research into practice. Selected strategies in each Centre were influenced by the typology of research products produced and the Centres' organizational heritage. The knowledge creation and adaptation phases were mainly facilitated by funders' guidance towards research impact and research product co-creation with patients and implementing organizations. Dissemination and implementation phases were often facilitated through utilizing support from university-based technology transfer offices to facilitate implementation and valorization and establishing and strategically leveraging formal infrastructure, such as public-private partnerships and professional collaborative networks.

CONCLUSIONS

Successful research utilization requires evolving researcher competencies to meet environmental demands and facilitating co-creation with research end-users and implementing partners. Understanding external determinants influencing research utilization in the Dutch dementia research ecosystem is crucial for capacity-building and aligning cross-sector agendas. The KTA framework appears to reveal the intricacies of research utilization, guiding future studies to explore strategies employed across various contexts.

Assessing the costs and savings of telemedicine: Insights from the consolidated framework for implementation research

Cost reduction is an often-cited reason to use telemedicine. In assessing telemedicine's cost and value, providers often turn to published cost analyses in the scientific literature for guidance. In this commentary on existing telemedicine cost analysis literature, we discuss the generalizability of these analyses and identify the Consolidated Framework for Implementation Research framework to help assess the applicability of a given cost analysis using inner- and outer-setting constructs. Outer-setting factors-location, practice type, and specialty-can substantially affect telemedicine cost and value, as can the implementation setting. While the body of evidence shows telemedicine may often reduce costs, there is still a need for robust cost analyses to guide implementation decisions as telemedicine becomes a mainstay of healthcare provision. Along with a call for more cost research, we ultimately argue that providers should consider a more holistic, value-based approach to determining when and how telemedicine implementation could benefit healthcare delivery.

Digital therapeutics as a new weapon against diseases: focus on the current European legislation and possible therapeutic strategies

INTRODUCTION

Digital therapeutics (DTx) are an emerging phenomenon within the scientific landscape which is attracting considerable international interest. This review aimed to provide an overview of the definition and classification of DTx, focusing on the contribution that DTx may provide in the treatment of a lot of diseases, compared with pharmacological treatments and highlighting it strengthens and weaknesses into the European regulatory landscape.

AREAS COVERED

They are software-generated therapeutic interventions directly to patients useful to prevent, manage or treat diseases. Digital therapeutics can come in many forms, including mobile apps, online programs, wearables, and virtual reality. The use of digital therapeutics has gained increasing attention in recent years as a potential alternative to traditional pharmacological treatments. According to the European legislation, DTx are not classified as medicinal products but as medical devices, and not always in a homogeneous way between different countries.

EXPERT OPINION

This regulatory lack could impact on the effectiveness of DTx in the European Union, which have the requirements to real impact on patients' health, like pharmacological treatments. It is therefore necessary to implement a stable regulatory system that can support conventional medicines prescriptions.

A scoping review on advancements in noninvasive wearable technology for heart failure management

Wearables offer a promising solution for enhancing remote monitoring (RM) of heart failure (HF) patients by tracking key physiological parameters. Despite their potential, their clinical integration faces challenges due to the lack of rigorous evaluations. This review aims to summarize the current evidence and assess the readiness of wearables for clinical practice using the Medical Device Readiness Level (MDRL). A systematic search identified 99 studies from 3112 found articles, with only eight being randomized controlled trials. Accelerometery was the most used measurement technique. Consumer-grade wearables, repurposed for HF monitoring, dominated the studies with most of them in the feasibility testing stage (MDRL 6). Only two of the described wearables were specifically designed for HF RM, and received FDA approval. Consequently, the actual impact of wearables on HF management remains uncertain due to limited robust evidence, posing a significant barrier to their integration into HF care.

"Towards harmonizing assessment and reimbursement of digital medical devices in the EU through mutual learning"

Digital medical devices (DMDs) present unique opportunities in their regulation and reimbursement. A dynamic landscape of DMD assessment frameworks is emerging within the European Union, with five clusters of prevailing approaches identified. Despite notable gaps in maturity levels, cross-country learning effects are becoming prevalent. We expect more countries, both within the EU and beyond, to follow the steps of current frontrunners, hence expediting the harmonization process.

Cardiovascular care with digital twin technology in the era of generative artificial intelligence

Digital twins, which are in silico replications of an individual and its environment, have advanced clinical decision-making and prognostication in cardiovascular medicine. The technology enables personalized simulations of clinical scenarios, prediction of disease risk, and strategies for clinical trial augmentation. Current applications of cardiovascular digital twins have integrated multi-modal data into mechanistic and statistical models to build physiologically accurate cardiac replicas to enhance disease phenotyping, enrich diagnostic workflows, and optimize procedural planning. Digital twin technology is rapidly evolving in the setting of newly available data modalities and advances in generative artificial intelligence, enabling dynamic and comprehensive simulations unique to an individual. These twins fuse physiologic, environmental, and healthcare data into machine learning and generative models to build real-time patient predictions that can model interactions with the clinical environment to accelerate personalized patient care. This review summarizes digital twins in cardiovascular medicine and their potential future applications by incorporating new personalized data modalities. It examines the technical advances in deep learning and generative artificial intelligence that broaden the scope and predictive power of digital twins. Finally, it highlights the individual and societal challenges as well as ethical considerations that are essential to realizing the future vision of incorporating cardiology digital twins into personalized cardiovascular care.

A smartphone app-based intervention combined with face-to-face sessions for alcohol dependence at internal medicine clinics: A randomized controlled trial

BACKGROUND

Addressing the limited access to treatments for alcohol dependence, we developed ALM-002, a therapeutic application to be "prescribed" for non-abstinence-oriented treatment in internal medicine settings. Our objective was to preliminarily assess the efficacy and safety of ALM-002.

METHODS

In a multicenter, open-label randomized controlled trial, participants aged ≥20 with alcohol dependence and daily alcohol consumption exceeding 60 g for men and 40 g for women, without severe complications, were randomly assigned to either the intervention group using ALM-002 or the treatment-as-usual control group. Participant in both groups received individual face-to-face sessions by physicians at weeks 0, 4, 8, and 12. The primary endpoint was the change in heavy drinking days (HDDs) from week 0 to week 12. A mixed model for repeated measures was employed.

RESULTS

We enrolled 43 participants: 22 in the intervention group and 21 in the control group. A significant reduction in HDDs every 4 weeks from week 0 to week 12 was observed, with a between-group difference of -6.99 days (95% CI: -12.4 to -1.6 days, standardized mean difference: -0.80).

CONCLUSIONS

These results indicate the potential of ALM-002 as a viable treatment for alcohol dependence. Further studies are needed to evaluate the clinical potential of ALM-002.

Digital Health Applications (DiGAs) on a Fast Track: Insights From a Data-Driven Analysis of Prescribable Digital Therapeutics in Germany From 2020 to Mid-2024

BACKGROUND

This study aimed to analyze the rapidly evolving ecosystem of digital health applications (Digitale Gesundheitsanwendung; DiGAs) in Germany, spurred by the 2019 Digital Healthcare Act. With over 73 million people in Germany now having access to DiGAs, these prescribable digital health apps and web-based applications represent a substantial stride in health care modernization, supporting both patients and health care providers with digital solutions for disease management and care improvement.

OBJECTIVE

Through a data-driven approach, this research aimed to unpack the complexities of DiGA market dynamics, economic factors, and clinical evidence, offering insights into their impact over the past years.

METHODS

The analysis draws from a range of public data sources, including the DiGA directory, statutory health insurance reports, app store feedback, and clinical study results.

RESULTS

As of July 1, 2024, there are 56 DiGAs listed by the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte), divided into 35 permanently and 21 preliminarily listed applications. Our findings reveal that a majority of DiGAs extend beyond the intended 1-year period to achieve permanent listing, reflecting the extensive effort required to demonstrate clinical efficacy. Economic analysis uncovered a dynamic pricing landscape, with initial prices ranging from approximately €200 to €700 (€1=US $1.07), averaging at a median of €514 for a 3-month DiGA prescription. Following negotiations or arbitration board decisions, prices typically see a 50% reduction, settling at a median of €221. Prescription data offer valuable insights into DiGA acceptance, with total prescriptions jumping from around 41,000 in the first period to 209,000 in the latest reporting period. The analysis of the top 15 DiGAs, representing 82% of the total prescriptions, shows that these best-performing apps receive from a minimum of 8 to a maximum of 77 daily prescriptions, with native apps and early market entrants achieving higher rates. Clinical evidence from all 35 permanently listed DiGAs indicates a uniform preference for randomized controlled trials to validate primary end points, with no noteworthy use of alternative study designs encouraged in the Digital Healthcare Act and related regulations. Moreover, all evaluated DiGAs focused on medical benefits, with health status improvement as a key end point, suggesting an underuse of patient-relevant structural and procedural improvement in demonstrating health care impact.

CONCLUSIONS

This study highlights the growth and challenges within the DiGA sector, suggesting areas for future research, such as the exploration of new study designs and the potential impact of patient-relevant structural and procedural improvements. For DiGA manufacturers, the strategic advantage of early market entry is emphasized. Overall, this paper underscores the evolving landscape of digital health, advocating for a nuanced understanding of digital health technology integration in Germany and beyond.

Mapping the regulatory landscape for artificial intelligence in health within the European Union

Regulatory frameworks for artificial intelligence (AI) are needed to mitigate risks while ensuring the ethical, secure, and effective implementation of AI technology in healthcare and population health. In this article, we present a synthesis of 141 binding policies applicable to AI in healthcare and population health in the EU and 10 European countries. The EU AI Act sets the overall regulatory framework for AI, while other legislations set social, health, and human rights standards, address the safety of technologies and the implementation of innovation, and ensure the protection and safe use of data. Regulation specifically pertaining to AI is still nascent and scarce, though a combination of data, technology, innovation, and health and human rights policy has already formed a baseline regulatory framework for AI in health. Future work should explore specific regulatory challenges, especially with respect to AI medical devices, data protection, and data enablement.

Tracing Digital Therapeutics Research Across Medical Specialties: Evidence from ClinicalTrials.gov

Digital therapeutics (DTx), evidence-based software interventions for preventing, managing, or treating medical disorders, have rapidly evolved with healthcare's shift toward online, patient-centric solutions. This study scrutinizes DTx clinical trials from 2005 to 2022, analyzing their growth, funding, underlying medical specialties, and other R&D characteristics, using ClinicalTrials.gov data. Our analysis includes trials categorized via the ICD-11 system, covering active, recruiting, or completed studies and considering trials listing multiple conditions. In analyzing 5,889 registered DTx trials, we document a more than five-fold increase in such trials since 2011, and a compound annual growth rate of 22.82% since 2005. While most trials were single-center, the median number of study subjects increased in recent years, driven by larger interventional trials. The key disciplines driving this growth were psychiatry, neurology, oncology, and endocrinology. Mental health dominated DTx trials in recent years, led by neurocognitive disorders, substance abuse disorders, and mood disorders. Industry funding varied across disciplines and was particularly high in visual system diseases and dermatology. DTx trials have surged since 2005, accelerated by recent growth in mental health trials. These trends mirror developments toward remote healthcare delivery, amplified by digital health investments during the COVID-19 pandemic. Growing numbers of participants in DTx trials point to increased demand for more robust trials. However, because most trials are single-center and country-specific, more international cooperation and harmonized evaluation standards will be essential for DTx trials to become more efficient and provide validation across countries, health systems, and groups of individuals.

"Your Package Could Not Be Delivered": The State of Digital HIV Intervention Implementation in the US

PURPOSE OF REVIEW

Despite continuous innovations and federal investment to create digital interventions addressing the HIV prevention and care continua, these interventions have not reached people in the U.S. at scale. This article reviews what is known about U.S. implementation of digital HIV interventions and presents a strategy to cross the research-to-practice chasm for these types of interventions.

RECENT FINDINGS

We conducted a narrative review of U.S.-based original research on implementation of digital HIV interventions and identified few studies reporting on implementation determinants, strategies, processes, or outcomes, particularly outside the context of effectiveness trials. To supplement the literature, in 2023, we surveyed 47 investigators representing 64 unique interventions about their experiences with implementation after their research trials. Respondents placed high importance on intervention implementation, but major barriers included lack of funding and clear implementation models, technology costs, and difficulty identifying partners equipped to deliver digital interventions. They felt that responsibility for implementation should be shared between intervention developers, deliverers (e.g., clinics), and a government entity. If an implementation center were to exist, most respondents wanted to be available for guidance or technical assistance but largely wanted less involvement. Numerous evidence-based, effective digital interventions exist to address HIV prevention and care. However, they remain "on the shelf" absent a concrete and sustainable model for real-world dissemination and implementation. Based on our findings, we call for the creation of national implementation centers, analogous to those in other health systems, to facilitate digital HIV intervention delivery and accelerate progress toward ending the U.S. epidemic.

The three-year evolution of Germany's Digital Therapeutics reimbursement program and its path forward

The 2019 German Digital Healthcare Act introduced the Digital Health Application program, known in German as 'Digitale Gesundheitsanwendungen' (DiGA). The program has established a pioneering model for integrating Digital Therapeutics (DTx) into a healthcare system with scalable and effective reimbursement strategies. To date, the continuous upward trend enabled by this framework has resulted in more than 374,000 DiGA prescriptions, increasingly cementing its role in the German healthcare system. This perspective provides a synthesis of the DiGA program's evolution since its inception three years ago, highlighting trends regarding prescriptions and pricing as well as criticisms and identified shortcomings. It further discusses forthcoming legislative amendments, including the anticipated integration of higher-risk medical devices, which have the potential to significantly transform the program. Despite encountering challenges related to effectiveness, evidence requirements, and integration within the healthcare system, the DiGA program continues to evolve and serves as a seminal example for the integration of DTx, offering valuable insights for healthcare systems globally.

Contents analysis of telemedicine applications in South Korea: An analysis of possibility of inducing selective or unnecessary medical care

The use of telemedicine and telehealth has rapidly increased since the start of the COVID-19 pandemic, however, could lead to unnecessary medical service. This study analyzes the contents of telemedicine apps (applications) in South Korea to investigate the use of telemedicine for selective or unnecessary medical treatments and the presence of advertising for the hospital. This study analyzed 49 telemedicine mobile apps in Korea; a content analysis of the apps' features and quality using a Mobile Application Rating Scale was done. The study analyzed 49 mobile telemedicine apps and found that 65.3% of the apps provide immediate telemedicine service without reservations, with an average rating of 4.35. 87% of the apps offered selective care, but the overall quality of the apps was low, with an average total quality score of 3.27. 73.9% of the apps were able to provide selective care for alopecia or morning-after pill prescription, 65.2% of the apps for weight loss, and 52.2% of the apps for erectile dysfunction, with the potential to encourage medical inducement or abuse. Therefore, before introducing telemedicine, it is helpful to prevent the possibility of abuse of telemedicine by establishing detailed policies for methods and scope of telemedicine.

Robot-assisted surgery and artificial intelligence-based tumour diagnostics: social preferences with a representative cross-sectional survey

BACKGROUND

The aim of this study was to assess social preferences for two different advanced digital health technologies and investigate the contextual dependency of the preferences.

METHODS

A cross-sectional online survey was performed among the general population of Hungary aged 40 years and over. Participants were asked to imagine that they needed a total hip replacement surgery and to indicate whether they would prefer a traditional or a robot-assisted (RA) hip surgery. To better understand preferences for the chosen method, the willingness to pay (WTP) method was used. The same assessment was conducted for preferences between a radiologist's and AI-based image analysis in establishing the radiological diagnosis of a suspected tumour. Respondents' electronic health literacy was assessed with the eHEALS questionnaire. Descriptive methods were used to assess sample characteristics and differences between subgroups. Associations were investigated with correlation analysis and multiple linear regressions.

RESULTS

Altogether, 1400 individuals (53.7% female) with a mean age of 58.3 (SD = 11.1) years filled in the survey. RA hip surgery was chosen by 762 (54.4%) respondents, but only 470 (33.6%) chose AI-based medical image evaluation. Those who opted for the digital technology had significantly higher educational levels and electronic health literacy (eHEALS). The majority of respondents were willing to pay to secure their preferred surgical (surgeon 67.2%, robot-assisted: 68.8%) and image assessment (radiologist: 70.9%; AI: 77.4%) methods, reporting similar average amounts in the first (p = 0.677), and a significantly higher average amount for radiologist vs. AI in the second task (p = 0.001). The regression showed a significant association between WTP and income, and in the hip surgery task, it also revealed an association with the type of intervention chosen.

CONCLUSIONS

Individuals with higher education levels seem to accept the advanced digital medical technologies more. However, the greater openness for RA surgery than for AI image assessment highlights that social preferences may depend considerably on the medical situation and the type of advanced digital technology. WTP results suggest rather firm preferences in the great majority of the cases. Determinants of preferences and real-world choices of affected patients should be further investigated in future studies.

eHealth implementation in Europe: a scoping review on legal, ethical, financial, and technological aspects

Background

The evolution of eHealth development has shifted from standalone tools to comprehensive digital health environments, fostering data exchange among diverse stakeholders and systems. Nevertheless, existing research and implementation frameworks have primarily emphasized technological and organizational aspects of eHealth implementation, overlooking the intricate legal, ethical, and financial considerations. It is essential to discover what legal, ethical, financial, and technological challenges should be considered to ensure successful and sustainable implementation of eHealth.

Objective

This review aims to provide insights into barriers and facilitators of legal, ethical, financial, and technological aspects for successful implementation of complex eHealth technologies, which impacts multiple levels and multiple stakeholders.

Methods

A scoping review was conducted by querying PubMed, Scopus, Web of Science, and ACM Digital Library (2018-2023) for studies describing the implementation process of eHealth technologies that facilitate data exchange. Studies solely reporting clinical outcomes or conducted outside Europe were excluded. Two independent reviewers selected the studies. A conceptual framework was constructed through axial and inductive coding, extracting data from literature on legal, ethical, financial, and technological aspects of eHealth implementation. This framework guided systematic extraction and interpretation.

Results

The search resulted in 7.308 studies that were screened for eligibility, of which 35 (0.48%) were included. Legal barriers revolve around data confidentiality and security, necessitating clear regulatory guidelines. Ethical barriers span consent, responsibility, liability, and validation complexities, necessitating robust frameworks. Financial barriers stem from inadequate funding, requiring (commercial) partnerships and business models. Technological issues include interoperability, integration, and malfunctioning, necessitating strategies for enhancing data reliability, improving accessibility, and aligning eHealth technology with existing systems for smoother integration.

Conclusions

This research highlights the multifaceted nature of eHealth implementation, encompassing legal, ethical, financial, and technological considerations. Collaborative stakeholder engagement is paramount for effective decision-making and aligns with the transition from standalone eHealth tools to integrated digital health environments. Identifying suitable stakeholders and recognizing their stakes and values enriches implementation strategies with expertise and guidance across all aspects. Future research should explore the timing of these considerations and practical solutions for regulatory compliance, funding, navigation of responsibility and liability, and business models for reimbursement strategies.