DIGA Mid-Term Conclusion: Think Of The Gatekeepers, Too!

When the Digital Health Care Act (DVG) came into force just over two years ago, many hopes were pinned on digital health applications (DiGA). But practice shows that even if the bureaucratic hurdles have been overcome, in the end the “vote with the prescription pad” often goes against DiGA – a mandate for the industry to adapt its approach more to the needs of prescribing physicians.

It’s nothing new that the e-health ecosystem often tends to fly under the radar of public perception. Health topics tend to be consumer topics, and even more so for a target group whose interest in digitization resembles a tender seedling that is only just beginning to grow. And even if digital health apps make it into the public spotlight, that doesn’t mean the context has to be a positive one: In the recent past, the greatest attention was brought by a broadcast of “ZDF Magazin Royale,” in which Jan Böhmermann took on the shortage of psychotherapy places and linked it directly to DiGAs. The tenor at the time: “You want to talk and can’t find a place for therapy? Then why don’t you do talk therapy with a bot?

The example shows: When DiGAs are publicly reported, they are often associated with the accusation of merely wanting to manage the shortage – or, even worse, as a stalling tactic to brush aside existing problems in the health care system with the blanket answer “innovation” (popular especially in debates on climate change). But DiGAs are anything but the “flying cabs” of the medical industry. And the industry is urgently called upon to counter this impression at an early stage. Good arguments, are – also because of the strict approval process of DiGAs – actually in abundance.

For DiGAs, measurable added value is part of the approval process: so why don’t we communicate it better?

In addition to the medical added value, DiGAs also create their approval because of the criteria of “procedurally and structurally positive care effects.” One such example is when patients have easier access to care, but also when an app promotes overall health literacy and supports the medical decision-making process. Compared with innovations from non-medical sectors, DiGAs have the advantage that they have already been put through their paces by an independent body – namely the German Federal Institute for Drugs and Medical Devices (BfArM). And as a companion to numerous DiGA projects, we at the Digital Medical Applications Center (dmac) can confirm that this test is no walk in the park. Against 30 applications that made it into the directory, eight received negative decisions and more than 60 manufacturers withdrew their applications, sometimes because of the strict regulations.

Although the strict approval practice causes many providers sleepless nights, it should also be seen as a seal of quality: DiGAs are serious medical products that are on an absolutely equal footing with other forms of therapy, and their manufacturers should therefore also be self-confident.

Apps offer low-threshold therapy approaches

In fact, the practice of the first two DiGA years also shows that by far not only apps from the fields of self-care and psychotherapy are prescribed. The current front-runners among the prescribed DiGAs are the tinnitus app Kalmeda, the anti-back pain training Vivira and the obesity therapy Zanadio. In the first year after the DVG came into force, these three DiGAs alone were prescribed a combined total of over 25,000 times – not because they fill a gap in care, but because they bring demonstrable additional benefits compared with conventional therapies – whether it’s integrating behavioral therapy against tinnitus into everyday life, having a detailed repertoire of exercises for back pain on your cell phone, or a weight loss app that favors long-term dietary changes over short-term dietary successes and maintains motivation for months. DiGAs’ low-threshold therapy approaches, like patients’ smartphones, are part of their everyday lives, making them by definition “closer” than a doctor could ever be.

Of course, DiGAs should never be a general answer to problems in healthcare – but neither should the potential of digital health applications go unused in everyday healthcare.

And here in particular, DiGAs that had cleared the high hurdles of approval faced the next, even greater obstacle in the first few years: “prescription pad reconciliation” by prescribing physicians. That’s because, according to a broad-based survey of DiGAs conducted by Stiftung Gesundheit, nearly half of physicians openly doubt the effectiveness of the applications that have made it into the DiGA directory. They refrain from prescribing just because of that. In addition, there are long-standing relationships and trust between doctor and patient. Physicians are often very aware of the individual life situation and motivation and therefore see no reason to deviate from the previous prescription practice.

For technology and service providers alike, this is a tough nut to crack in one fell swoop. Here, the service providers are specifically asked to explain their apps better and more transparently and to create trust. This also shows the greatest fear that physicians express towards DiGAs: Despite DSGVO and costly approval, data protection concerns are clearly the biggest obstacle. Over 70% cite this factor as the main reason against prescribing.

However, the survey also shows that once physicians have the opportunity to deal with DiGAs, the recommendation rate increases enormously. DiGA manufacturers can therefore hope for a continuously increasing habituation effect, but should also take active measures to promote it.

The key to this lies in the applications themselves. It is important not to simply wait until physicians have had a chance to learn about their app on their own, but to invest in measures that focus on actual use: This includes trial access, walkthroughs, tutorials, but also support where real people work. These and other measures help satisfy physicians’ need for self-information as “gatekeepers.” Statements made by physician representatives in the first DiGA years suggest that there is still room for improvement in marketing. With the exception of a few social media spots and information flyers, doctors hardly came into contact with the topic, as the Handelsblatt noted last year.

From our experience as dmac in projects over the last few years, we can emphasize how important early communication with the various stakeholders is. DiGAs are patient-centric solutions – digital assistants in the hands of patients. They are designed to benefit patients and improve their healthcare. However, manufacturers must not forget that not only patients need to recognize the benefits of DiGAs, but also gatekeepers such as physicians who prescribe DiGAs or insurance companies who may alternatively approve them at the request of the insured without a physician’s prescription. Both stakeholders must be convinced that the costs of a DiGA are offset by corresponding benefits. This benefit must be communicated. It doesn’t hurt to speak a little “medical German” now and then.

You can find the complete article in the current issue of EHEALTHCOM.

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