Longyear Health
The Smartphone and the Internet-Digital Health Enablers
I grew up at the very tail end of the Millennial generation and the very beginning of Gen Z. Collectively, we are a strange group because we grew up in a very analog and non-digital world, but we fully witnessed the rapid transformation to digital. I witnessed the complete transition from floppy discs to DVDs to streaming and the entire evolution from flip phones through the very first smartphones. My age group is not filled with digital natives, but rather digital pioneers. We remember a time before smartphones, Wi-Fi, and Netflix.
When I was in sixth grade, my best friend Charlie called me on my Samsung Glide phone to tell me about this new service from Dell he had just discovered—Dell Video Chat. The very next day, I begged my Dad to take me to Target so I could buy a webcam to hook up to my laptop in order to video chat with Charlie via Dell Video Chat. This was my first experience with very early capabilities of synchronous audio/visual signals transmitted over the internet in real time. I remember being incredibly excited about this innovation—the potential seemed limitless.
Today, audio-visual communication technologies like Apple’s FaceTime and Zoom are ubiquitous. Just like millions of others, I spend hours of my life on Zoom calls each day. The technology enables people to work from anywhere and to collaborate with colleagues around the world. With applications like FaceTime, friends and family are a few screen-touches away. As internet networks (e.g., 3G, 4G, and 5G), Wi-Fi, and smartphones took the world by storm, societies changed remarkably.
The digital world has become more and more accessible and powerful. It has impacted essentially all industries, people, and even animals as organizations and individuals have built their online presence. It quickly became clear that the use cases are endless. Driving the digital revolution, two primary innovations have shepherded the digital health industry: the internet and the smartphone. Without these two inventions, there would be no digital health efforts to undertake.
Expanding on the first iteration of the internet, broadband wireless internet access both in homes and through direct wireless connections to smartphones has further expanded the use and potential for these technologies. The power to transmit data, media, and communications in milliseconds across the globe has transformed human society. Smartphones have provided computer processing capabilities and endless information directly into the home and the hands, or pockets, of millions of people.
The US Perspective
My focus has been on the healthcare system of the United States and, by extension, those of the developed world that share similar clinical institutions and regimes. Among these health systems, the United States performs relatively worse. But, the internet is well suited to help drive significant change moving forward. Indeed, the digital health revolution will help solve some of the serious gaps in the US health system as they relate to the programs that actually drive patient benefit.
After all, good healthcare is often as much about patient education, communication, and engagement as it is about anything else. This is one aspect of the internet that we know works exceptionally well when done properly. To better understand the digital health movement and its place in the future of healthcare, it is important to establish an understanding of the current internet and smartphone trends.
In the United States, the internet expansion has been closely measured by Pew Research Centers.[i] The growth in US adults who use the internet rose sharply from approximately 50% in the year 2000 to greater than 80% in 2018.
Rural Areas
Despite steady growth over the last two decades, with respect to internet usage. This is particularly applicable to healthcare discussions surrounding the use of digital technologies due to the promise of improved access in areas with limited physical healthcare service locations.
Individuals who reside in rural areas tend to have a low supply of healthcare providers and often must travel a longer distance to reach them.[i] Rural areas have historically poorer access to healthcare services across specialties.[ii] In a similar trend, evidence suggests that children in rural areas are less likely to receive advice about a healthy diet, exercise, and the risks of smoking than are children in urban areas.[iii] Overall, hospitals located in rural areas have more complex and sicker patients than those facilities in urban areas.[iv] In addition, many of these key disparities between rural and urban areas increase in magnitude for individuals who are African American or Hispanic.
As a general rule, populations in rural areas are more likely to be older, poorer, sicker, and uninsured.[v] They also have higher rates of opioid use disorder, injury, smoking, and suicide. Life expectancy is often used to compare the health of populations between geographic areas. Over time, the life expectancy in rural areas has gone down at a faster rate than that of many urban areas overall.[vi] It is important to mention here that within urban areas, there also exist wide disparities in life expectancy, where one zip code can show a significantly lower life expectancy than a nearby zip code.
The Global Perspective
The internet has been one of humanity’s most transformational and exponential technologies. Globally, the number of internet users increased rapidly from just around 413 million in 2000 to over 3.4 billion in 2016.[i] In 2005, the 1 billion user milestone was achieved. From 2011 to 2016, each day saw an average of 640,000 people who gained access to the internet for the first time.[ii]
Looking at data[iii] compiled by Max Roser and colleagues in 2015, with respect to internet use across the globe, China and India take the top two slots in terms of total internet users despite having only 50% and 26% of their populations online, respectively. The top six countries by number of internet users in 2016 were:
China = 765 million
India = 391 million
United States = 245 million
Brazil = 126 million
Japan = 116 million
Russia = 109 million
In a similar manner to the internet, mobile technology has also spread exponentially around the globe. In 2018, it was estimated that approximately 5 billion people owned mobile devices.[iv] Of those mobile devices, somewhere over half are smartphones.[v] Despite the large ownership numbers in aggregate, the growth in mobile technology to date has not been uniform across countries or across populations within them.
People in advanced economies are more likely both to own a smartphone and to have access to the internet than those people in emerging economies. For example, a median of 76% of the population across 18 advanced economies surveyed have smartphones, compared with a median of only 45% of people in emerging economies.[vi] This inequity can be seen as cause for concern, but the numbers are still remarkably high and represent a major opportunity for health services from global and domestic perspectives.
The inter- and intra-country expansion of both internet access and smartphone ownership has led to an explosion of innovation. Healthcare has been no different. Globally, the promise of digital health quickly meant the efficient provision of healthcare services and expertise to remote areas or those geographic areas that are medically under-resourced. As internet and devices reach increasingly remote areas, this promise is realized. Once access is achieved, the opportunities for use case expansion are vast.
The internet expansion to the developing world, in the global healthcare community, has tremendously improved capabilities and reach for innovative healthcare organizations and nongovernmental organizations. This is likely one of the most significant impacts of the digital health revolution, and it is one that I am far too underqualified to discuss in detail. It is important to note that the gains in healthcare quality and access to medical care driven by the use of digitally delivered health services in areas of the developing world should not be understated.
Older Adults
When thinking about a population that has high rates of chronic illness and that can benefit from technology, the first that comes to mind is older adults. Older adults represent a higher proportion of the population in rural areas and experience a high prevalence of chronic illnesses associated with aging. Older adults also often experience mobility issues and challenges with their activities of daily living.[i] As much of the global population ages, this core group of societal elders will become an increasingly important group for healthcare and social service systems.
With decreased mobility comes difficulty accessing needed healthcare services. A higher risk for chronic illnesses coupled with this difficulty accessing services leads to a population at risk for bad health outcomes and costly episodes of care.
One of the biggest critiques of the digital health industry is the perceived inability for older adults to access and use the technologies in their care. However, the data tells another story, one that is rapidly changing.
In Figure 3.2, again from Pew Research data, the percentage of adults who report using the internet is shown from the year 2000 until 2018.[ii] Adults older than 65 have progressed from a reported usage at well below 25% in 2002 to close to 75% internet use. The entire population, in fact, is converging quickly on 100% utilization at the current rates, as approximately 10,000 people turn 65 each day in the United States. Thus, those individuals in younger age groups continue to bring their internet use and smartphone ownership into US Medicare eligibility.
Figure 3.2 Percentage of US Adults Who Use the Internet, by Age.
The benefits of using digital technology to deliver healthcare, for older adults, are numerous. Given the increased access to and adoption of the internet within this population, the potential exists to solve some important problems associated with an aging populace.
For older adults with mobility issues or those geographically distant from a physical healthcare provider, the delivery of health services and check-ins over the internet offers a convenient and accessible alternative to face-to-face care.
Similarly, the delivery of services via the internet can also allow for more touchpoints with older adults who already experience loneliness at higher rates than other age groups. Older adults often report that their visit to their doctor is one of their main social interaction opportunities. Thus, the replacement of in-person care is not reasonable, but rather the addition of new virtual touchpoints or the use of virtual care when physical care is not possible can provide social interaction opportunities for older patients.
Importantly, digital tools can be specially designed for the use of older adults to improve usability and engagement. Some companies in digital health have built specially designed applications and tablets to improve visibility and in-app navigation for older adults.
It is clear, however, that as we continue to move into the next 20 years of healthcare transformation, internet access rates will continue to improve for all age groups, enabling the continued growth of digital health models.
[i] This trend is driven by natural effects of aging but also can be impacted and exacerbated by lifestyle, socioeconomic factors, and access to healthcare services over time.
[ii] Pew Research Center. “Mobile Technology and Home Broadband 2019.” June 2019. Online. www.pewresearch.org
The Smartphone
According to the Cambridge Dictionary,[i] a smartphone is a cell phone that can be used as a small computer and that connects to the internet.
Just as the internet network continues to spread through the population, across geographic areas, into the home, and into the pockets of millions of people, so did the computer. Together with the internet, this trend has also set the stage for the digital health movement.
I grew up with a flip phone during the time that the Motorola Razr was the coolest phone on the market. Cell phone technology grew up right before our eyes during the early 2000s. After my first flip phone, I graduated to one of the first touch screen phones available, the Samsung Glyde. It was a poorly functioning and comparatively small screen accompanied by a slide out, horizontal, full keyboard that was still needed to use the SMS-text function due to the limitations of the touch screen.
The first iPhone commercial began running on television in mid-2007, and I vividly remember seeing it for the first time. It was striking. The functionality, the modernity, and its limitless potential were clear. Apparently, it became clear to everyone else as well because the smartphone market exploded quickly in the years after.
Pew Research Center collects information on cell phone use, and it was not until about 2011 that they included smartphones in the survey. But, the data shown in the Figure 3.3 is still telling of the impact smartphones have had on US society.
From a rate of ownership hovering just above ~30% in 2011, smartphone ownership rates climbed to above 75% of the US population in 2018. The high rate of adoption has prompted a rush to develop applications and tools for these pocket computers that accompany their owners in most situations. Apps have hit the market for thousands of use cases, with health being a chief pursuit among developers.
Figure 3.3 Percentage of US Adults Who Own Smartphones and Cell Phones.
The power of the smartphone for use in healthcare resides in three concepts: the ability to transmit data and information, the ability to facilitate communication between the owner and healthcare service providers, and the fact that the phone is never too far from its owner.
Health is with a person at all times, and so too is the smartphone. It is this concept plus the technical capabilities of the phone–internet complex that provides the scaffold on which healthcare services can more effectively impact health.
[i] Cambridge Dictionary, s.v. “Smartphone.” Accessed August 2020. Online. https://dictionary.cambridge.org/us/.
Smartphones and the Internet: Population Segments
Digital health services and programs require the use of an expensive smartphone and continuous internet access. Thus, one of the primary criticisms aimed at the digital health movement are concerns about equity.[i] Will the growth and expansion of healthcare solutions delivered via smartphone leave people behind who cannot afford smartphones? Will access go only to the wealthy? Will the widespread use lead to a two-tiered system of healthcare with one for the poor and one with technology for the rich? Will rural areas with comparatively lower rates of smartphone ownership and internet use be left behind further? These are all questions that must be answered and addressed by the industry in conjunction with both state and federal policymakers moving forward.
The same Pew Research Center data[ii] further provides insights into the distribution of smartphone ownership across the US population. In total, 81% of the population reports owning a smartphone. In Table 3.1, smartphone ownership is evaluated across a number of demographic, socioeconomic, and geographic categories. There are several relevant conclusions to be drawn.
Table 3.1 Distribution of Smartphone and Cell Phone Ownership, by Category
| Any cellphone | Smartphone | Cellphone, but not smartphone |
Total | 96% | 81% | 15% |
Men | 98% | 84% | 14% |
Women | 95% | 79% | 16% |
Ages 18–29 | 99% | 96% | 4% |
30–49 | 99% | 92% | 6% |
50–64 | 95% | 79% | 17% |
65+ | 91% | 53% | 39% |
White | 96% | 82% | 14% |
Black | 98% | 80% | 17% |
Hispanic | 96% | 79% | 17% |
Less than high school graduate | 92% | 66% | 25% |
High school graduate | 96% | 72% | 24% |
Some college | 96% | 85% | 11% |
College graduate | 98% | 91% | 7% |
Less than $30,000 | 95% | 71% | 23% |
$30,000–$49,999 | 96% | 78% | 18% |
$50,000–$74,999 | 98% | 90% | 8% |
$75,000+ | 100% | 95% | 5% |
Urban | 97% | 83% | 13% |
Suburban | 96% | 83% | 13% |
Rural | 95% | 71% | 24% |
|
|
Source: Survey conducted January 8 to February 7, 2019.
First, most people have some form of cell phone. Even in the 65+ age group, 91% have either a smartphone or a non-smartphone cell phone. This is the category with the lowest number reported for that column. Thus, engagement with all ages, areas, and demographics is possible via voice transmission or SMS-text—and many health technology companies are building programs designed to use this more basic technology to better engage patients who may not have or easily use a smartphone. While the functionality may be less rich than a program delivered via smartphone, the engagement and communication capabilities are still available.
Second, with respect to income, there is a disparity in smartphone ownership between the wealthy (95%) and those of low income (71%). While only 5% of people making more than $75,000 do not have a smartphone, 29% of people making less than $30,000 a year report not having a smartphone device. Thus, folks with lower incomes are at a technological disadvantage. This is the root of the argument that digital health has an equity problem.
Third, looking at race and ethnicity, disparities appear smaller than those seen when segmenting the population by income. Among whites, 82% report having a smartphone, while the black and Hispanic segments of the population report 80% and 79%, respectively.
Fourth, just like with internet access, there is a disparity between urban/suburban communities (83%) and rural (71%) ones with respect to smartphone ownership. This is a major limitation when it comes to the goal of extending health services to locations with geographic access issues to face-to-face health services. But, taking a glass half-full approach, it is promising to see the rates of both internet access and smartphone ownership consistently growing in rural areas. For those with both internet access and a device, the delivery of digitally augmented healthcare services is possible.
Fifth, education level segmentation shows a disparity between more highly educated people and those with less than a high school education. Those with a college degree have a 91% smartphone ownership rate, whereas those with less than a high school education report 66% ownership. This effect is likely due to income driven by education differences rather than inherent differences due to the education itself. Many of the differences seen here within other categories may be a result of income differences rather than the effect of the segment itself. Smartphones are comparatively expensive compared to non-smartphone cell phones.
Finally, with respect to age group differences, the data shows that people aged 18 to 29 have the highest rate of smartphone ownership, while older adults aged 65+ have a much lower rate of smartphone ownership, at 53%. Many older adults utilize a desktop computer to access the internet and therefore may be able to access digitally delivered health services via a computer. However, it is my opinion that 53% is a strong number that supports the idea that the unique advantages of these digital models can be conferred to many older adults; rates of ownership are also increasing.
[i] This is a big current conversation and clear issue in the entirety of healthcare.
[ii] Pew Research Center. “Mobile Technology and Home Broadband 2019.” June 2019. Online. www.pewresearch.org
A Note About Equity and Disparities
I would be remiss if I failed to highlight and specifically address the current disparities and inequities that exist in healthcare and in health outcomes among racial groups. I took a positive lens when evaluating the current state of internet access and smartphone ownership to suggest that the current increasing trends and rates of ownership are positive for digital health’s ability to meet patients across a wide variety of demographics.
However, health disparities are rampant in healthcare. The Pew data illustrates a similar story to the disparities seen in health outcomes. Lower-income, rural, older, black, and Hispanic populations have lower rates of smartphone ownership and internet access than wealthier, white, urban, and younger populations. This divide exists in health outcomes across a wide variety of measures. For example, rural areas have higher rates of chronic illness than suburban areas, black mothers have higher rates of maternal mortality than white mothers, and older adults have higher rates of loneliness than younger populations.
While the rates of smartphone ownership and broadband internet access across all demographics are improving, it will be important to monitor disparities created due to the provision of healthcare services via digital tools. If digital health companies and virtual care delivery models are built to improve health outcomes, then the very people who need them most may not have sufficient access. This possibility should not be ignored, and proactive steps to ensure access should be taken by companies and the greater healthcare ecosystem.
Virtual care models and digital health companies have emerged as solutions to some of healthcare’s most crucial issues to address. Any disparities resulting from their use would represent a failure to deliver on promises. This represents an important area for collaboration between policymakers and industry leaders.
**
Chronic disease is highly prevalent in the US population, especially conditions like heart disease, cancer, and diabetes. Having a low income, living in a rural area, or being older are all risk factors that are highly associated with chronic illness. The people in these demographic categories also have comparatively lower access to the internet and smartphones than other groups, making the equitable delivery of digital healthcare models a challenge. But, the rates of smartphone ownership and internet access are increasing across all segments of the population.
Despite the disparities, looking at the current numbers, more people than not have a smartphone and internet access across any segment of the population. Thus, as these numbers continue to grow, the potential for the delivery of clinical services via smartphones is well established.
The problems of healthcare services and the health of the US population will not be solved through the simple fact that there is shift in modality from entirely face-to-face services to mixed virtual services. The improvement of access through the use of internet-delivered services is a crucial development in and of itself, but the real power of digitally enhanced care delivery allows for the creation of entirely new models of care and interventions to address health more holistically—and to measure performance in real time.
[i] The Covid-19 pandemic prompted a number of initiatives to address internet access and technology needs in rural areas and in impoverished populations. In the early days of the pandemic, the Federal Communications Commission (FCC) launched a fund designed to extend this crucial access.
References
[1] Max Roser, Hannah Ritchie, and Esteban Ortiz-Ospina. “Internet.” 2015. Published online at OurWorldInData.org. https://ourworldindata.org/internet [Online Resource]
[1] Ibid.
[1] Ibid.
[1] Pew Research Center. “Mobile Technology and Home Broadband 2019.” June 2019. Online. www.pewresearch.org
[1] Ibid.
[1] Ibid.
[1] Ibid.
[1] National Healthcare Quality and Disparities Report Chartbook on Rural Health Care. Rockville, MD: Agency for Healthcare Research and Quality; October 2017. AHRQ Pub. No. 17(18)-0001–2-EF.
[1] Ibid.
[1] Ibid.
[1] Ibid.
[1] Ibid.
[1] Ibid.
[1] This trend is driven by natural effects of aging but also can be impacted and exacerbated by lifestyle, socioeconomic factors, and access to healthcare services over time.
[1] Pew Research Center. “Mobile Technology and Home Broadband 2019.” June 2019. Online. www.pewresearch.org
[1] Cambridge Dictionary, s.v. “Smartphone.” Accessed August 2020. Online. https://dictionary.cambridge.org/us/.
[1] This is a big current conversation and clear issue in the entirety of healthcare.
[1] Pew Research Center. “Mobile Technology and Home Broadband 2019.” June 2019. Online. www.pewresearch.org
[1] The Covid-19 pandemic prompted a number of initiatives to address internet access and technology needs in rural areas and in impoverished populations. In the early days of the pandemic, the Federal Communications Commission (FCC) launched a fund designed to extend this crucial access.