Timothy Aungst, PharmD: Many people from my pharmacist background, we see patients who are prescribed medications, therapy across so many conditions, but the reality is that I don't know if they take them half the time. There's different data out there, whether you want to look at medication possession ratio, but that just tells you that they paid for something, make claim on it. That isn't telling me someone adjusted therapy. For many of us having to talk to patients, we ask, “Did you take your medication?” How did they respond? More likely than not, patients will report negative outcomes, such as adverse events or average drug reactions compared with benefit. The benefit could take time in patients. For example, you put them on an SSRI [selective serotonin reuptake inhibitor], and they may respond, “It's been a week. Why don't I feel better yet?” You have to explain how it works. What's the mechanism of action vs DTX [digital therapeutics] and these PDTs [prescription digital therapeutics] are out there? Patients have this on their phone or through their medium that they can communicate through. They can see it and be like, “Okay, I'm doing these sessions. I'm giving feedback to this device and software, and I can see my action improvement.” They can see how they're responding to therapy, but they know that their provider's seeing that too. It's no longer going to wait 2 months to follow-up with my physician. You feel trust. Someone's seeing this and can see I'm doing better or not doing as good, and they can act on that. Personalization jumps out tremendously compared with traditional pharmaceutical medications. The issue is that data and how patients and clinicians have access to interpret it. It’s a changing paradigm of how we look at care overall.

John Fox, MD: The patient and the provider are getting real-time or near real-time feedback. Anyone want to react to that?

Scott Whittle, MD: There's a lot of value added to it. I know of health care systems that have chosen to use a tiered approach, where they're comfortable writing the prescription because somebody shows up in the emergency department or in one of their receiving centers, and they know the engagement piece is complicated. They're willing to write that prescription upfront, watch the engagement, and then, maybe in a tiered way, manage that person through the health care system through using the dashboard if that individual needs an increased level of engagement. Ideally, we would always have that engagement piece with providers and with the patient themselves using the portal. Some health care systems are recognizing they don't have access to that kind of resource, and they're going to do the best they can with it.

Timothy Aungst, PharmD: That's one area I've been critical of. We look at the market-shaping strategies across DTX right now; a large focus is on certain providers—eg, DOs [doctors of osteopathic medicine] NPs [nurse practitioners], PAs [physician’s assistants], etc—but the reality of the situation in digital health as a whole is that many providers don't have the time to sit back and look at that data. We know that's going to be dropped down onto ancillary staff underneath. My thought has been that we need to think about how we use involved nursing staff, pharmacists, therapists, and invest their time to take on some of that stuff because, to your point, how you triage—whether it's texting service through SMS or having a human coach come in—and then triaging that to the top level you want to go. Again, we're going to hit an issue of human scalability in the backend, that we don't have the time to look at all this data. Who's going to look at it? Who's going to intervene? Where do you want to intervene? At what level? I don't know of any provider that wants to be pinged on a Saturday night for minute kinds of things, but who should take that on? That's a conversation that should be explored further on. At some point, that comes back to the payers as well. If you want to make this work, you have to consider who's going to be touching this at the end of the day. There are prescribers up there, but the digital health and digital therapeutic spreads through the ecosystem, and you need everyone on board to make this function.

Arwen Podesta, MD: I 100% agree, Tim. That's a valuable thing to think about and for payers to think about, reimbursement for time. I am on the Steering Committee for Psychiatry congress, a large conference. I've asked a lot of my psychiatry colleagues about digital therapeutics. I ask people's thoughts on it, and they’re scared to take on something else. First, they don't know enough about it, so they don't want to prescribe it, but then once they do know about it, the biggest barrier for the prescriber is the time commitment. At least on the ones that I've used frequently for opioid, alcoholism, and insomnia, the studies show that monitoring that dashboard by the clinician is actually part of what makes the digital therapeutics successful. Those that don't monitor it, it's not as successful without that key important piece. Who's going to spend the time doing it? For me, I have to have a little reminder during my administrative time twice a week to look at it, and then I send emails or texts or have my assistant do the same to patients, whether they're using it or not using it—giving them compliments on how excited I am about their improvement or how I'd really like them to get it started because then we have 20 days left on the prescription. I try and keep an engagement, and that's one piece of what makes it successful. We have to think about where that time commitment is going to come from.

Transcript edited for clarity.