Diving Into Digital Health

Top down view of feet at end of diving board with water below.

With digital health tools improving patient outcomes and changing the way pharmacists deliver care, pharmacy schools are starting to integrate digital health education into the curriculum to prepare students for rapid advances in technology.

By Jane E. Rooney

As it did with so many facets of our lives, the pandemic altered routines and changed the way patients received medical care in the past year. Many providers were forced to move appointments online and practice telehealth, which comes with its own skillset. In addition to being able to communicate effectively with patients remotely, healthcare professionals need to be well versed in using platforms such as Zoom or mobile apps. Meanwhile, patients must be able to access the technology on their end. As the digital health landscape expands and telehealth and other virtual platforms become more widely used, what can pharmacy schools do to prepare graduates to enter practice settings that are more reliant than ever on emerging technologies?

As pharmacy schools consider how to incorporate digital health education into the curriculum, one immediate hurdle is that there is no universal definition for digital health, nor is there standardized material to be included under that umbrella. The International Pharmaceutical Federation (FIP) published a digital health report earlier this year to investigate the readiness and responsiveness of pharmacy education to train the current and future pharmaceutical workforce. Dr. Timothy Aungst, associate professor of pharmacy practice, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, was an adjunct committee member and helped FIP with survey construction in addition to authoring several chapters of the report focused on the educational landscape and needs for digital health in medical education. His research revealed that efforts to incorporate digital health education into the curriculum are introductory at best across the Academy. “Some schools are moving toward digital health now but there’s a concentration in telehealth and pharmacy services,” he said. “The biggest discord I see is when schools talk about it, they think it’s informatics 2.0, which it isn’t, or that it means digitalization of services. Digital health in terms of capitalizing on remote patient monitoring, mobile health wearable sensors and digital therapeutics is relatively brand new.”

I see further pushes toward remote care, teleservices, monitoring remotely and doing treatment. Smart medications are coming to market that track adherence. Even with MTM services, a few companies are trying to use AI to make that go faster. With all of this technology, pharmacy schools need to step back and say, what is changing in healthcare? Where is our best value statement that we can put ourselves out there?

Dr. Timothy Aungst

He sees this deficit in digital health knowledge as something that must be addressed now that the pandemic has accelerated the “hospital at home” model with devices coming on the market (and companies such as Amazon getting involved) that allow patients to share data with providers. “There is really no pharmacy school that has made digital health a huge part of their program. Some have done odds and ends or an overview,” he explained. “[The FIP survey] illustrated that a lot of schools thought they were offering digital health but had limited expertise. The survey asked, if we were to engage in it, how would you teach it? What kind of technologies should you look at? Should we teach students how to program or how to do remote patient monitoring? I don’t know what the best answer is. There’s an opportunity for pharmacy schools and organizations to come together and say as stakeholders, what do we want to engage with versus what we don’t need to talk about. There are a lot of technology companies out there that don’t know that pharmacists fit into this so we’re being ignored. If there was more emphasis from the profession as a whole, we could see new jobs and opportunities for our students to leverage.”

Some pharmacy schools have made strides integrating digital health into the curriculum and recognize that it needs to be a priority. They discuss what is working, what is still missing and what student pharmacists need going forward to thrive in the digital health world.

Tracking Emerging Tools

Dr. Ana Hincapie, assistant professor, University of Cincinnati James L. Winkle College of Pharmacy, suggests that schools start by identifying areas where digital health can be incorporated into an existing curriculum. For example, student pharmacists are already learning about diabetes in terms of therapeutics, so information can be added to courses to include discussions about apps for diabetes care management and how to advise patients. “One of the biggest barriers is that some of these new tools were developed without patient input,” she noted. “We need to be teaching our students usability in terms of the devices so they can better consult with patients. New tools will be developing such as biosensors. We need to improve the usability of those tools and recommend things that are appropriate and personalized for those patients.”

She favors a team-based learning approach and said that it lends itself to a hybrid model of teaching, which many schools were forced to use during the pandemic. “The philosophy of it is that some of the basic content is expected to be acquired before class. We have prerecorded videos and when students come to class, they have to demonstrate that they’ve mastered that content by taking a quiz individually,” she explained. “With team-based learning, they benefit by testing themselves in a group and getting interactions with the team and answering the same quiz. All of those conversations that happen in the team enrich the learning experience. They can discuss why they chose one answer over another. As a faculty member you can introduce more advanced experiential education and spend less time on something that students can master on their own.”

Hincapie said pharmacists need to become familiar with the personalized aspect of digital health, which is rapidly expanding. “We need to work on more in exposing our students to the potential benefits of these tools and also talking about their limitations.” Digital health applications offer benefits beyond improved patient outcomes. “It expands pharmacists’ opportunities in terms of career paths,” she continued. “For example, you say to a patient, you have to take your statin and change your diet. How can a pharmacist help incorporate using those digital health tools with pharmacotherapy? If the patient is already in the pharmacy, he or she doesn’t need to go to a different provider—you might as well do both.”

As Aungst sees it, one place to start is by addressing the lack of continuing education for faculty. “We need to empower faculty to have a better knowledge base about this stuff,” he said. “Some ability to help train pharmacists who are going to teach students is needed. Schools could come together and talk about how to integrate standards. For the time being it will be every school for themselves. That’s the most realistic scenario right now.”

He added that schools have to consider what patient care is going to look like in the future and acknowledge the landscape students will be entering. “I see further pushes toward remote care, teleservices, monitoring remotely and doing treatment. Smart medications are coming to market that track adherence,” he pointed out. “Even with MTM services, a few companies are trying to use AI to make that go faster. With all of this technology, pharmacy schools need to step back and say, what is changing in healthcare? Where is our best value statement that we can put ourselves out there? The recent empowerment of technicians to do things like administer vaccines…I don’t see that being rolled back. I can see them being empowered to do more. What clinical services offer value and what can pharmacists do? The digitalization of healthcare and integration of digital health tools will change how healthcare is conducted.”

The pandemic ushered in changes in healthcare delivery that had to be implemented quickly, some of which are likely here to stay. “We saw the drastic change with telehealth in 12 months. The technology was already there but we had no incentive to use it. Now the incentive is there,” Aungst said. “With the fee-for-service model, with the volume of patients getting seen in person go way down we saw health providers and health systems lose a lot of money. Those that had value-based models did fine in the pandemic because they swapped their models out to focus on keeping members healthy. They were using services like telehealth and they were still doing fine. This has opened up a conversation about pushing value-based services even further to reach patients in the home. You’re going to see more people going toward these business models.”

A New Virtual World

Lipscomb University College of Pharmacy & Health Sciences has several health informatics offerings, which include a strong digital health component. A required health informatics course in the P2 year covers areas such as electronic health records, data analytics, blockchain technologies and virtual health. IPPEs and internships offer additional opportunities to learn about digital health tools. “The leadership for Lipscomb really identified informatics as key for pharmacy right from the beginning,” noted Dr. Kevin Clauson, associate professor, Department of Pharmacy Practice. “Informatics was going to be a core component for the entire profession. That enabled us to explore a lot of opportunities for our student pharmacists.” He emphasized that students do hands-on work and recommended that colleges of pharmacy look beyond teaching and research and try to partner with companies to engage in digital health within the broader community.

“We provide virtual reality headsets to all of our students. With blockchain, they are directly interacting with networks. We try to get introductions to things like coding,” he continued. “We’re not trying to teach them to be programmers, but we want them to be exposed to baseline, fundamental knowledge that they would be working with out in practice. We’re mindful to say, ok, if you have an interest in digital health and you’ve explored how to use this technology to improve patient outcomes, what sort of career opportunities are there for you? We show them specific resources and career opportunities and other broader areas they can look to in order to extend the role of the pharmacist going forward as well.”

Student pharmacists now recognize the roles for these technologies. Before there were a lot of challenges that might have been tougher for them to see beyond, but now they are all seeing it being incorporated in practice. I try to give more specific real-world examples of how digital health is not just improving outcomes but is also financially sustainable.

Dr. Kevin Clauson

Dr. Beth Breeden, associate professor, Department of Pharmacy Practice, said that Lipscomb student pharmacists were prepared to use Zoom and other platforms for telehealth prior to the pandemic but it prompted faculty to broaden the discussion to optimizing these tools to deliver clinical outcomes. “Virtual health was available but not utilized as significantly due to reimbursement restrictions,” Breeden explained. “Due to COVID-19, those visits are reimbursed just as in-office visits would be. The question is if those reimbursements are going to remain. There’s a lot to consider from a regulatory standpoint, so we introduce that to students so they understand the business model as well. Organizations had to implement virtual health very rapidly and have seen success with it. A key feature is to ensure that providers as well as patients can use the virtual health platform, so training and education remain important on that front.”

Clauson, who is one of the experts tapped by the FDA to advise its new digital health center of excellence, added that the college refined its instructional approach to reflect the changing state of healthcare. “Student pharmacists now recognize the roles for these technologies,” he said. “Before there were a lot of challenges that might have been tougher for them to see beyond, but now they are all seeing it being incorporated in practice. I try to give more specific real-world examples of how digital health is not just improving outcomes but is also financially sustainable.” He said that COVID-19 has changed how we seek access to and deliver healthcare, prompting additional career opportunities for pharmacists.

Breeden noted that support from administration and an already well-trained faculty were instrumental in the college’s early success in digital health education. “I had worked in the informatics space for several years as had Dr. Clauson, who came from a background of digital health. We also sought to maximize collaborations with healthcare organizations and that offered great opportunities,” she said. Clauson added that focused, dedicated courses and longitudinal integration are key. “That integration is usually the easier first step for schools that don’t have people with focused expertise, but I think it’s really important to engage with faculty who don’t have this as their primary focus because it’s going to be integrated throughout practice, he said. “As an example, Dr. Jessica Wallace is our expert on asthma, and while she isn’t focused on informatics, she does incorporate digital health technologies for managing asthma and COPD so students are as practice-ready as possible when they graduate.”

The University of South Florida Taneja College of Pharmacy has also made informatics and digital health a core component of the curriculum. “Informatics is one of the four pillars that underpin our current curriculum,” said Dr. Amy Schwartz, associate dean for academic affairs. “The founding dean felt strongly that incorporating technology in the curriculum was important. We are constantly looking for different ways to enhance it in any capacity.” While digital health is an all-encompassing term, faculty try to adjust what they teach as technologies change, said Dr. Aimon Miranda, associate professor, pharmacotherapeutics & clinical research.

“We’re talking about mobile health and wearables. Early on, a lot of it was focused on the medication use process, and now it’s shifted more toward an exploratory kind of course,” Miranda explained. “Students are evaluating mobile apps and mobile devices, looking at what is on the market. We consider if we had to counsel patients on wearable devices, which patients would benefit from them? We also look at issues in the healthcare system—how could we implement a digital solution? Their midpoint project is exploring emerging technologies and how those could be implemented in the healthcare field or if it’s been used in another industry, how it could be applied to the healthcare field.”

Schwartz pointed out that we often assume students are tech savvy because they have grown up with technology, but that is not always the case. “They come up to speed pretty quickly but you have to teach them the educational technology first so it does not impede learning,” she noted. “We had to do that with faculty as well.” When the pandemic forced the shift to remote learning, faculty had to be trained quickly to use online platforms.

“We really had to break down the different softwares that were available to them and talk about classroom response—how do you get engaged when you’re no longer face to face? We covered things like camera etiquette and microphone etiquette,” said Davina Devries, learning and development manager. Ensuring that students are able to troubleshoot a platform also became a priority over the past year. “We’re giving the students the ability to develop problem solving for technology in the clinical setting and a technical setting. At least then they have the baseline skills to figure out what they will need in the clinic.”

The pandemic required some additional training and finessing to prepare students to function in virtual environments. “I think there is a skillset involved with how to build patient rapport and we should be planning to implement that,” Miranda noted. “We have to think about the skillset a student needs to interview a patient. Making sure you turn on your camera, thinking about your background and whether it’s distracting…there are some soft skills there. It’s about e-health literacy in general. Some of the patients we see in the clinic are high-risk patients. Are they able to get online? Are they able to access a Teams conversation? Can they set up their appointments?”

Our society used to tell a patient what do to and hoped they would do it. Using technology can help you better assess compliance and hold patients more accountable. You can have those crucial conversations—what do you want to accomplish with your health? What are your goals?

Dr. Amy Schwartz

Schwartz concurred that students need to hone those skills. “They need to be prepared to assess their patients. Using listening and nonverbal communication skills to be able to assess patients are going to be very important.” She added that flexibility will be crucial since the platforms being used in various healthcare settings are not standardized. “There’s a level of standardization they need to be exposed to so they can understand how to readily adapt because it’s impossible for us to teach about all available systems.”

Miranda said that faculty do address interoperability issues so students understand the challenges associated with digital health, such as ethics, privacy and security issues, and legal and regulatory issues. “We introduce them to some of those concepts so they appreciate the environment they are working in.”

Enhanced Patient Engagement

Digital health presents an opportunity for shared decision making and for patients to be more proactive about their care. “If the patient is engaged and involved in their care, their outcomes are better,” Miranda emphasized. “If we start having them use devices or transmit information to us, we can use that in real time. We have healthier patients with digital health if we train the patients right.”

Schwartz added, “Our society used to tell a patient what do to and hoped they would do it. Using technology can help you better assess compliance and hold patients more accountable. You can have those crucial conversations—what do you want to accomplish with your health? What are your goals?” She conceded that while digital health affords clinicians better efficacy and efficiency, wearable technologies do pose affordability and privacy concerns. “We’re partnering with preceptors to provide access to our students and making sure they provide instruction on the technology that’s available at those institutions. For students, seeing [these tools] used in practice is probably the most impactful mechanism. Not all of our institutions have access to digital resources, so sometimes practice is ahead of education, sometimes it’s behind.”

Lipscomb’s Breeden agreed that outcomes will improve as patients are enabled to take greater control of their care by using digital tools. “It is an exciting time in healthcare as innovation continues to lead the way,” she said. “The ability for a patient to receive care in their home via telehealth and have medications delivered to their front door via drone is almost a reality. Subsequent monitoring of those patients via wearables rounds out that cycle. It is important to prepare students to be practice ready for this emerging environment.”

Clauson pointed out that the FIP report helped raise awareness that digital health education needs to be accelerated. “Digital health and informatics is and should be a priority. How do we communicate the value of it?” He said pharmacists can leverage technology to address medication adherence and start to overhaul the country’s episodic healthcare system. “You may visit a pharmacist, your primary care provider, your dentist…it’s very siloed. What digital health has the potential to let us do is move beyond episodic healthcare into a continuum to be able to interact with patients and provide care when needed. Leveraging that technology to move to a continuum is one of the greatest opportunities that digital health offers and allows pharmacists to expand and improve patient outcomes.”

MCPHS University’s Aungst echoed Clauson’s assertion that digital health platforms can improve medication management as well as medication safety. He also believes it offers a means to collect real-world data about the effectiveness of pharmacists’ interventions. “Why can’t the pharmacist monitor therapy when a patient gets discharged from the hospital? These are new possibilities for us, we just have to figure out how we train ourselves to handle it. When this is achieved it offers better incentives for pharmacists to be involved in patient care,” he said. He favors opening the door to conversations with digital health companies about how pharmacists can work with them.

“I’d like to see the Academy take a serious shot in terms of determining what is the best way to integrate and position our future graduates as members of a digital health team that can function in a way that increases job opportunities,” he continued. “Digital health increases pharmacists’ abilities to work as subject matter experts at tech companies or serve as digital health coaches for new clinical businesses that we’ve never been tied to in the past.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.