Hello, everyone. I'm Alain Labrique, professor and associate chair for research in the Department of International Health here at the Johns Hopkins Bloomberg School of Public Health. And I also serve as the Inaugural Director of the Johns Hopkins University Global mHealth Initiative. I've been working in the space of digital health now for over a decade. Working closely with international normative agencies and implementing agencies on understanding then refining the nuances of using appropriate technologies to strengthen health systems and clinical service delivery. So it's my pleasure today to speak with you about several features and facets of digital health as it's emerged as a field. I'm focusing first on taxonomy and then working through specific use cases of how we see digital health in the world of healthcare today. So [COUGH] we're going to cover a number of topics including describing and defining the origins of the term digital health. Understand a little bit about taxonomy, which may sound a little bit geeky to many of you. But for any emerging new field as we try to speak to one another, especially when that field is interdisciplinary and spans engineering, public health medicine, and technology. There's certainly a lot of shared language that has to be developed and agreed upon as you move forward. I think over the last decade, we've seen marked growth in this space of digital health. And what I'd like to do is maybe speak through a few of the key milestones that have really grown this field as an area of investment and research over the past ten years. We're also going to talk a little bit about ways in which digital health is being used for COVID-19 mitigation. So let's begin with basic definitions. This has been a area of intense debate and discussion over the past decade as we've gone from the world of telemedicine and mhealth or mobile health to now referring to the space writ large as digital health. That really encompasses a wide range of electronic health, mobile health, digital health. In fact, this is the working definition that's currently being used by the World Health Organization and the United States Agency for International Development. And that is the systematic application of information and communications technologies, computer science, and data to support informed decision making by individuals, by the health workforce and by health systems. For the purposes of improving health and wellness for all and to strengthen resilience to disease. So, as you might imagine, this definition took not just months but years to come to a consensus around which words should be used. And as you can see the Venn diagram that it describes is one that encompasses a wide range of technologies that are being used. My own focus and research has really been in the space of mobile health. And that is the application of this definition to interventions that really focus on leveraging the global mobile phone revolution and that has really transformed the landscape, especially in low and middle income countries. Now combining technology and health is certainly not a novel idea. The earliest instance of telemedicine goes back to the mid 1940s when, I believe it was in Philadelphia, physician was able to send X-ray images using telephone signals. But the idea goes even further back than that as you can see here on these Magazine covers from the 1920s when radio was just becoming a household technology. Where the idea of a future that we could consult patients remotely and even manipulate them using bedside laparoscopic techniques was already being thought of. So there's really nothing new under the sun when it comes to thinking creatively about what's possible in the future. But I think what really for me as an infectious disease epidemiologist changed this landscape was observing on the ground as I was working in rural Bangladesh, the mobile phone revolution. Which as you can see here illustrated in this changing map, how the countries of Sub-Saharan Africa and South Asia dominate the globe in terms of mobile phone ownership and access. In contrast to the populations of North and South America and even Europe. Now, what's exciting here is that the countries that you see inflating in the Sub-Saharan Africa and in the Indian subcontinent. Are also the countries which have persistently suffered from an inordinate burden of maternal and child morbidity and mortality over several decades. So an exciting opportunity for those of us working in the space of public health. And so the idea of what is remote and rural is now redefined by the universal access that we're seeing in almost every corner of the globe to mobile telephony. A few years ago, I happened to be traveling through a small part of rural Kenya in a district where there was very little electricity, as you can see, there's no electric wires going around the back. And where frankly mobile telephony was at least for my AT and T phone, something that was not available. But as we looked at these mud huts, we began to see numbers etched into the walls of these huts. And as I asked our guide, what was this number, thinking that he would tell me about some malaria program or a local census. He looked at me quizzically because, of course, this was the individuals mobile phone number that was written on the walls and not allowing anyone who was looking for this gentleman to be able to reach out and contact him. And so even in the most rural parts of the globe, we're starting to see if not direct ownership of mobile technology, ability to access individuals using these networks. Now digital divides do remain, and we do have an important chasm of trying to bridge socioeconomic and gender gaps that persist in terms of ownership of mobile devices. But certainly, the reach of networks and the penetration of this technology even in rural remote areas has increased quite dramatically. We're starting to see the use of advanced technologies as you might imagine. We're starting to see the reach of even advanced technologies penetrating into rural populations. As we see for example, here this micro SD card is a common way in which bootleg copies of recent videos are shared across village networks. And to think about the opportunity that this reflects in terms of being able to share engaging health content with either community health workers or families trying to optimize the health of their children and family members. So what is a taxonomy? And this is what we said we would talk about. And it's really critical as we have an emerging domain or space of science, it's important that we all agree to speak a common language. So that as we refer to our work, as we refer to the type of innovation or the nature of the innovation, what's in the proverbial syringe that we're delivering care through or the innovation by which we're accelerating a particular challenge of care delivery. Are we using the same words to describe common things? And that basic establishment of a shared vocabulary is critical to being able to both understand the diversity of use cases within an emerging field. But also to be able to classify like with like as we work to synthesize evidence and understand the evidence base around whether a particular strategy is effective to solve a public health or clinical problem that we're trying to address. If you're calling something an orange and I'm calling something an apple and fundamentally they're the same thing. We may not understand that we are actually doing the same intervention unless we're using those same language. So many of you may have memories of or nightmares of your middle school or high school biology where you learn this particular method of classification of living things from domains to species. But there can be other schemes of classification depending on how things look, how things behave, what types of technologies are being used by a particular intervention. And so that's really what we're going to be talking about for the first part of this series. So going back to one of the most interesting stories for me about taxonomies is in the early 18th and 19th centuries, the efforts that were being made by naturalists around the world to classify the world around us. And describe animals and flora that was being observed especially as exploration was becoming more widespread using the sort of common language. In fact, I'm using here the example of the platypus, which you can imagine befuddled naturalists exploring the wilds of the Australian continent. Coming back and describing a fur bearing animal that could lay eggs but also had the bill of a bird. And really being taken quite as a joke, as opposed to being a serious report when they returned to England with their observations of what they had seen in the wild. But it was important for these naturalists to be able to describe clearly the features and capabilities off the animal that they were trying to explain to their colleagues. What were the capabilities of this animal? What were the needs that the animal had in terms of an environment? And all of these can be translated as we're thinking about technologies to understand what does the technology comprise of? What elements come together to make the so called platypus of our digital health intervention? What are the dependencies of this animal to exist in the wild? Do we need to have a particular kind of network? Do we need to have particular type of processing power in order for our so called digital platypus to work in the real world setting? And so it's really critical to be able to have this language to speak about technologies. Now, confusion and debate is bound to characterize any new field. And one of the things that we observed with digital health was in fact this proliferation of taxonomy as people were trying to make sense of this emergent world where we have commercial companies developing new innovations. We had clinicians and public health professionals working with technologists to develop strategies to improve health systems and medical care. And so as you see on the left here is a fairly unstructured Venn diagram that digital health encompasses this whole spectrum of things from mHealth to health IT to EHRs to big data. And really I don't find this particular taxonomy to be very helpful because all of the circles coexist in this mess of overlapping diagrams. Whereas on the right, another noteworthy attempt where you can start to see smartphone apps now being classified across a number of features. So we have the functions, the ratings, the medical claim or the evidence, the attributes, and then the features that are integrated into that. And so you can sort of go through this hierarchy and start to tag the the particular application you're describing using these various facets. And so still not a very clear type of descriptor because there's a melding of technologies such as GPS or microphone, camera with other aspects such as surveys or calls or functions or alerts. Which are separate from the actual technology? So as you think about what is the hardware? What is the software? What are the functions and what is the enabling environment needed for a technology? You can start to really disentangle these components in a much more clear way, which is sort of where we've headed over the past several years. So as an intellectual exercise, because I know we won't have an opportunity to do this together. What I'd love for you to do is maybe pause right now for a moment on this slide and reflect on an example of digital health that might come to your mind. And either discuss with a classmate or with others around you, the facets that you would identify to describe uniquely digital health technology that comes to your mind. Maybe you're thinking about a Fitbit. Maybe you're thinking about a Garmin smartwatch. Maybe you're thinking about a dietary tracking app like MyFitnessPal or maybe you're thinking about software for training community health workers in rural India. All of these are perfectly valid examples of digital health interventions. But ask yourself, are you describing a piece of hardware? Are you describing a piece of software or an application? Are you describing a conglomerate that uses both a particular hardware and a software applied for a purpose that is a health or public health purpose that's being sought after as part of this intervention? What channels are being used or is any channel being used? That is to say text messaging or Internet or or data or GPRS, right? What are the dependencies in terms of the channel and who is the intended user? Is the intended user a client, a patient, a well person, an ill person? Is it a provider of care or is it a system manager? So all of these things are really critical to think about as well as why, right? For what is this technology and software being used? What is the problem that's being solved by this technology? And I think as we start to refine the way in which we describe what it is we're doing and how we're doing it and why we're doing it, we begin to achieve a certain degree of clarity around what we're describing. Such that others can understand whether or not the work that they're doing is similar or is different to the work that we're doing now. Now, there is also an important distinction that I want to point out and that is when we speak about digital health, it's critical to understand that we're not just talking about apps. Apps are perhaps one facet, one software facet of the digital health world that can be very specific to a platform or operating system or or technology stack, that's required in order for that application to work. These software solutions usually are vetted by the library on which that software is available, either the Android Google Play store or the IOS app store. Usually they have some very specific predefined functionality. They don't have much extensiblity, that is to say features and new facets are not easily added. And in the historic past, there have been few controls on the content authenticity. That is to say you'd often find a disclaimer at the bottom of the apps saying for entertainment purposes only, this content has not been approved by the FDA or by other professional organizations. Now, one exception has been during the COVID-19 pandemic. Both of these stores have actually applied fairly rigorous filters to ensure that the COVID-19 applications that are being placed onto these libraries were at least achieving some modicum of competence or qualification. Either reviewed by clinical personnel or coming from entities that have typically created medical content such as teaching universities or hospitals
