Digital health apps and digital capabilities have the potential to lower costs and increase access to healthcare in analogous manner to efficiency gains and service improvements found in other sectors. However, to achieve such benefits digital health solutions need to be well designed and implemented. Reviews of solution implementations have shown that poorly designed digital health apps or services decrease societal fairness and further widen the gap between those who can readily access services and those who find this challenging – the so-called ‘digital divide’ (Saeed and Master, 2021). To address the issue of a digital divide, IHT researchers have developed a manifesto intended to guide the development of digital health solutions, concentrating on those that are offered to consumers, with the aim of promoting fairer and inclusive access to healthcare.
The term ‘digital health’ includes the use of health apps on mobile devices or using digital devices to access healthcare information or services. Given the broad release of mobile health apps into the marketplace and their wide adoption, it might be easy to draw a conclusion that such apps (and digital health more generally), would show a clear positive benefit for society e.g. through easier access to services, greater efficiency or easier access to health information (see for example What is Digital Health? on the U.S Food and Drug Administration website). Unfortunately, like many introductions of new technologies, this optimism has not proven to be universally true (Kim et al. 2017).
In 2020, the COVID-19 pandemic provided a test case of the use of a specific digital health intervention: the ‘contact tracing app’, which was originally expected to help track those with contact exposure to the virus (Pandet et al. 2022). There were many technologically different approaches to contact tracing adopted globally, but all had the stated aim of informing the user or a health authority if the user had been exposed. There were publicly stated concerns about transparency, and lack of clarity about how data would be used. There were also concerns that marginalised groups would not use or trust the app if it was not highly usable, and offered in their language.
In a bid to address these concerns, the Australasian Institute of Digital Health (AIDH) and the Australian Healthcare and Hospital Association (AHHA) jointly produced ten principles for good practice in design of a suitable contact tracing app that would increase trust and would not worsen the ‘digital divide’.
In 2021, researchers at IHT developed a guidance framework (D-HEAL) (Hensher et al. 2021) for evaluating digital health apps, which was subsequently field-tested by a major health insurer which used D-HEAL to recommend three mental health and wellness apps for the public. Key criteria emerging from the research were the degree to which the apps use inclusive communications, accessible design and provide appropriate transparency. Researchers at IHT considered whether it would be possible to build upon the criteria of good design implied by the D-HEAL: framework in combination with the ten COVID-19 specific principles, to develop a more general ‘good design’ digital health app manifesto.
The IHT team merged the D-HEAL framework and the AIDH/AHHA design principles into a broader manifesto suitable intended to be suitable for guiding the development of digital health apps and reducing the digital divide.
The resultant manifesto is:
All proposed digital health apps or services designed to be digitally accessed for the purpose of healthcare should abide by these principles to maximise societal benefit and minimise unfairness and disparities in access to services or knowledge:
- The user experience must be optimised for accessibility and inclusivity. Inclusive and accessible design with user experience and communication optimised for clarity and transparency and awareness of the potential to increase the ‘digital divide’. The user experience must be optimised for accessibility and inclusivity, including people with disabilities or those who may have limited digital literacy. Clear, purposeful and transparent communication with the public is required, with full disclosure about the digital health app’s purpose, design, performance, governance, and how the app benefits different communities. Communications must be in plain language and translated into multiple languages to ensure accessibility for people with different language backgrounds and should be designed to not require a digital literacy hurdle in order to be used. Resources and training materials, partnering with schools and libraries, and offering workshops or classes to help people develop the necessary skills should be offered if it is likely that use of the app would require skills or knowledge more than generally available to the target community. To further reduce the digital divide, the development and implementation of the digital health app could involve partnerships with community organisations, health providers, and other stakeholders. These partnerships will help to ensure that the app is accessible to a wider range of users and that the benefits of digital technologies are available to all.
- Safety by design. The digital health app must be designed with safety-by-design concepts to ensure it is inherently robust, safe and secure. There must be clarity of purpose. The app ideally should work offline or in areas with limited connectivity to ensure availability to people living in remote or underserved areas. Any algorithms or data used for training of algorithms, should pay careful attention to reducing bias and how to deal with confounding artefacts. The app should be based on referenceable and testable evidence and be developed and supported by credible developers who demonstrate commitment to support and updates. The content or information used by the app must be current and valid. If the app uses gamification techniques, then such usage must be for the purpose of appropriate user engagement and not to create a dependency or false sense of urgency in use of the app.
- Minimum data collection and specific scope. Data collection must be the absolute minimum required for effective use. The scope of the digital health app must be specific and focused on addressing the health needs of different communities. If the app requires data to be collected by, or shared with other sources then such interoperability should be via commonly published or supported standards and frameworks, for example Fast Health Interoperability Resources.
- Data security and sovereignty. Where any individually identifiable health data is collected then the data must be stored and shared on secure servers located in Australia that meet the standards set by the Australian Signals Directorate. The choice of data storage must leave no room for doubt about the ability of the Commonwealth of Australia to ensure that all citizen data remains only in this country. Legislative protections must ensure that no Australian data can be repatriated offshore to a foreign agency or government.
- Usage must be optional with full transparency and user control over device and data permissions required and granted. Use of the digital health app must be optional, with fully informed consent, and users must have control over their data and the mobile device permissions requested must be transparent and the minimum required for functionality. The app should remind users regularly that it is running in the background and be made aware of the device permissions have been granted to it. There must be clear criteria for what will constitute the end of life for the app, and its removal from devices should be appropriate for the purpose.
- Privacy protection and governance oversight. No other agency or third party may have access to this data, without specific permission of the user and such usage must be fully transparent and subject to appropriate regulatory acts with governing body (such as privacy regulator, the Office of the Australian Information Commissioner).
- Evaluation and continuous improvement. Continuous improvement of the app and its features must be based on community feedback and needs, ensuring that the app is meeting its goals and objectives. Independent evaluation should be available about the app and its use of data to ensure that it is meeting the needs of different communities and reducing the digital divide.
The research team further considered whether ChatGPT capabilities might be able to further reduce the digital divide in other ways. After putting this question to ChatGPT4, some interesting additional suggestions were generated by it:
- Use ChatGPT to assist in generating locally relevant content in multiple languages to foster digital inclusion.
- Utilise ChatGPT in educational programs to teach digital skills, enhancing the digital literacy of underserved populations.
- Leverage ChatGPT to create more intuitive user interfaces, making it easier for people with limited digital skills to access ICTs.
- Use ChatGPT to develop tools and resources tailored to the needs of people with disabilities, ensuring that they can access and use digital technologies effectively.
- Train ChatGPT to respect and adapt to cultural differences, promoting a more inclusive digital environment.
- Utilise ChatGPT to provide resources and mentoring for local entrepreneurs, helping them develop digital solutions that address community-specific needs.
- Use ChatGPT to analyse data and provide insights on the effectiveness of digital inclusion efforts, helping to guide future strategies.
Not all of these suggestions are practical, for example there is no current way for the community at large to “train ChatGPT to respect and adapt to cultural differences, promoting a more inclusive digital environment” since such training must currently be performed by the owning organisation: OpenAI. Training of ChatGPT cannot currently be requested to be made specific to the needs of digital health app developers. The other suggestions are interesting and will be considered by the D-HEAL and IHT researchers. We look forward to your thoughts and contributions to this manifesto.
We call upon developers and promoters of digital health to adhere to the principles of our manifesto to ensure access to services and societal fairness.
If you have further questions, or thoughts to share, perhaps you’d like to share those on our Padlet discussion board.
Affil. A/Prof, Paul Cooper was a co-author of the original AIDH/AHHA set of principles and was also involved in the IHT research into mobile health app evaluation (which was funded by the Medibank Better Health Foundation).
References
Article: “Principles for the COVID-19 Contact Tracing App” https://digitalhealth.org.au/wp-content/uploads/2020/05/AIDH_AHHA_Principles-COVID-19-App_FINAL_5-May-2020.pdf
Blog: “What is Digital Health?” | FDA (https://www.fda.gov/medical-devices/digital-health-center-excellence/what-digital-health )
Blog: “Will the Government’s coronavirus app COVIDSafe keep your data secure? Here’s what the experts say” – ABC News (https://www.abc.net.au/news/science/2020-04-27/covidsafe-contact-tracing-app-coronavirus-privacy-security/12186044 )
Blog: “The top 3 apps to help with stress and anxiety” (https://www.medibank.com.au/health-support/mental-health/articles/3-best-apps-for-stress-and-anxiety/
Hensher, M, Cooper, P, Dona, SWA, Angeles, MR, Nguyen, D, Heynsbergh, N, Chatterton, ML, & Peeters, A “Scoping review: Development and assessment of evaluation frameworks of mobile health apps for recommendations to consumers”, Journal of the American Medical Informatics Association, Volume 28, Issue 6, June 2021, Pages 1318–1329
Kim, MO, Coiera, E & Magrabi, F 2017 “Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review” Journal of the American Medical Informatics Association, 24(2), pp. 246–260
Pandet, JA, Pandit, JM, Radin, GQ & Topol, EJ. 2022 “Smartphone apps in the COVID-19 pandemic”, Nature Biotechnology, 40, July pp. 1013–1022
Saeed, SA, & Masters, RM “Disparities in Health Care and the Digital Divide” 2021 Current Psychiatry Reports, 23, 61, pp. 1-6
