Uber needs no introduction. Since its inception, just over a decade ago, it has succeeded in revolutionizing an entire industry. Coming on the heels of the “applification” of our everyday lives, what were the ingredients for its success? Was it ‘really’ the app? And what does this all mean for the future of healthcare as we know it?

In recent years the number of health apps has proliferated considerably. Today, there are a dizzying number of them available at our fingertips. Some are designed to manage a multitude of chronic illnesses or mental health conditions, others to help us relax, sleep, stretch, breath, exercise — you name it.

Do any of them work? Yes, some do, and very well, as I wrote in my last article about the behavioral changes spurred by one of the more successful apps.

Why then is the adoption curve for broader digital health apps in clinical practice so lacklustre?

Simply put, we are overfocussed on the app itself.  There are lots of great apps, but that isn’t the only factor that will drive their adoption and use. Digital health apps can very well revolutionize the future of healthcare, but a number of conditions necessary for this to happen are either lacking or in their nascent stages.

But first, for comparison’s sake, let’s take ridesharing apps. If you’re like me, you’ve been in and out of an Uber car too many times to count. Let’s face it, Uber and other ridesharing apps are like having your own personal limousine service; always at your beck and call, wherever you are. And please, don’t get me started on why taxis just don’t get it.

I can’t possibly imagine explaining this app to my late father. You use your phone, pick your destination and… voila! … a person in a car, with the name and picture you were shown, arrives a few minutes later. Without saying a word, that person takes you wherever you’re going; you get out and walk away, your payment already made.

What’s interesting is that the app itself is probably the least important predictor of success for Uber. Sure, it has to work well, but an entire ecosystem and a whole slew of underlying systemic conditions needed to be in place before Uber could ever see the light of day. Without these factors, the Uber model would have simply never worked, let alone risen to prominence.

Broadly speaking, 6 conditions needed to be met, 3 technical and 3 societal and behavioural.

Ce qui est intéressant, c’est que l’application elle-même aurait probablement été incapable de prédire son propre succès. Bien sûr, pour réussir, elle devait bien fonctionner. Mais tout un écosystème et une série de conditions systémiques sous-jacentes devaient aussi être mis en place avant qu’elle puisse naître. Sans de tels éléments, le modèle Uber n’aurait tout simplement jamais marché et ne serait pas devenu si important.

De manière générale, six conditions devaient être réunies, soit trois techniques et autant de sociétales et de comportementales.

The technical ones are the most obvious: 

1. Cellular networks needed to be widespread and support broadband data access.
   Cellular networks were developed in the 1970s, but it wasn’t until 1996 that digital signals could access mobile devices. The first 3G networks appeared in the mid 2000’s, and it’s no coincidence that Uber didn’t launch until 2008.
2. Phones had to be equipped with accurate GPS, and maps needed to be current and digitized.
   While the first GPS equipped phone was introduced in 1999, it wasn’t until 2000 that the US government ended the “selective availability” that hampered the accuracy of previous civilian-oriented versions. Without this, Uber could never have sent cars to a specific address. As for maps, Yahoo! Maps was only launched in 2004, and Google Maps in 2005. Uber could not have been launched before then.
3. A critical mass of people had to have mobile smartphones
   Smartphone ownership in the US was less than 20% in 2010.  It wasn’t until 2016 that about 70% of Americans owned a smartphone, and that is precisely when Uber revenues started taking off.

The societal and behavioral enablers are at little less obvious:

4. The ability and inclination to accept e-commerce transactions.
   While e-commerce dates back to 1979, it’s safe to say it did not enter the mainstream until much later. We may take PayPal and other payment systems for granted today, but the common, secure use of e-commerce transactions that are now so widely accepted did not occur until the mid-2000’s.
5. Trust.
   Uber could never work without trust. Just think about it, every time you step into an Uber, you are trusting the reliability of a perfect stranger and their personal vehicle. While Uber has its own checks and balances, the ground had already been broken by other trust-based transaction systems. eBay pioneered this societal change that had two strangers buying and selling goods with no assurance other than the mutual rating system. Uber uses this same method to maintain a dynamic assessment of rider and driver quality.
6. The availability of surplus cars.
   Uber would be lacking drivers were it not for a surplus of vehicles in a household. In fact, since 2000, the number of three-car number of three-car households in the US has increased to the point where now only less 9% of Americans have no vehicle.

Based on these conditions, it is fair to say that if ridesharing was launched in 2000, it would be a colossal flop and that it simply would not have worked.

So, what are the necessary conditions for digital health apps to take flight and revolutionize healthcare as we know it? If we used ridesharing as a barometer, we still aren’t quite there yet. Some of the key ingredients are there, but the pieces of the puzzle have not been put together.

The technological, societal and behavioural conditions for the widespread adoption of health apps is the subject of my next article. Stay tuned.

Les conditions technologiques, sociales et comportementales nécessaires en vue de l’adoption généralisée des applications de santé feront justement l’objet de mon prochain texte. À bientôt.

Ravi Deshpande, PharmD is a pharmacist, and Chief Business Development Officer for ELNA Medical.

The views expressed are those of the author

I hate running. For me, running is boring, slightly uncomfortable, repetitive and I never seemed to make much progress at it. I practise plenty of other sports, but last year, COVID put a damper on all of them. So, after much humming and hawing, I decided to take up indoor and outdoor running. Did I mention I hate running? Hoping for the best, I downloaded a running app to motivate me.

The app seemed pretty straightforward — you got a pre-programmed set of runs which gradually increase in length and intensity, culminating in a 10K run.

Whatever, I said. Let’s just get on with it.

That’s when I met Her. She was the voice coach for the app. Hers was an easy-going British voice, eternally sunny, smooth and comforting, warm as honey. Firm but fun. Her confidence and gentle encouragement were endearing. When She cheered, “Fantastic! You’ve been running nonstop for three minutes now!” I wondered what she’d say when I hit 40 minutes.

At first, She was there for every little step. But then I noticed She became strategic with Her comments. Sometimes I expected a little praise but got nothing. I kept trying harder, striving to merit hearing Her gently encouraging voice.

Then, the more I ran, the more I wanted to win Her approval. Meanwhile, I was making steady progress with my program: I hit 5K in less than two months and was moving on to longer runs. The app was really working. Spurred on by Her steady encouragement, I went from hating running to looking forward to my sessions. In fact, I would have run more frequently, but She, ever solicitous, gently reminded me I needed to rest to avoid injury.

After a few weeks went by, I began to wonder: do I actually have a crush on my running coach? And I wasn’t alone! On the chat group blog for the app, everyone wanted to know who She was, and I could completely relate. It was what She said and how She said it. She was neither aloof nor bossy, but somewhere in between: supportive at exactly the right time and strategically silent at others. What did She look like? Where did She live? We all assumed She ran, but was coaching Her full-time job? Honestly, we all wanted to meet Her.

You can imagine our disappointment when we learned that She was in fact a digitally created voice. Our English Rose was in fact likely a perfectly ordinary programmer working out of a basement in Manchester.

The moral of this story is that digital apps that are well designed and take into account basic human psychology and key elements of interaction between people can impact behavior. That running app certainly did it for me — even though taking up running this way seemed a vastly underwhelming prospect.

The long periods of time we spend without guidance about our health, away from the watchful eye of our doctors, nurses, pharmacists, and hospitals, can constitute a real and significant health care gap. For 23 hours and 55 minutes each day, we make a thousand solitary self-management decisions that affect our health, and we may at times feel alone, overwhelmed, despondent, or confused. The fact is, those with illnesses live with their condition 24/7. They need support that the health system cannot possibly provide them in person. Enter the well-designed digital health app that offers structured, relevant, customized, and well-timed interactions.

2021 marks the beginning of the digital health care era. The timing is right: COVID-19 has taught us that in-person care is not always possible. Conversely, many of the conditions that will make digital health apps effective are in place. (More on that in a subsequent article.)

You’ve all experienced bad apps, the ones you use for a few days or weeks and then just discard. How are current apps different? A lot of them aren’t — so many simply don’t make the grade among the legions that are being created. But the production of literally hundreds of these apps will ensure 1) “survival of the fittest” (apps), and 2) a more sophisticated set of users who recognize what makes an effective app stand out: the one that supports demonstrable and sustainable behavioral change. That is why I’ve recommended the aforementioned running app to anyone who will listen.

Apps alone will never be a substitute for in-person health care. But combined with intelligently designed platforms that curate and bring together digital and physical care, they optimize and extend the reach and influence of health care.

Ravi Deshpande, PharmD is a pharmacist, and Chief Business Development Officer for ELNA Medical. The views expressed are those of the author.