Digital health for analog humans: Changing human roles and responsibilities in the digital transformation of health systems This document discusses how digital transformation is changing the roles and responsibilities of various human actors in healthcare systems. It notes that while digital health technologies are becoming more prevalent, humans still play central roles. It explores new roles for patients and citizens who may generate and share their own health data, for healthcare professionals who must learn new digital skills, and for health informatics specialists. The document advocates that educators and researchers should help ensure digital transformation supports human needs and responsibilities.

1. Digital health for analog humans:
Changing human roles and responsibilities
in the digital transformation of health systems
October 2019
Associate Professor Kathleen Gray, The University of Melbourne
KGray@Unimelb.edu.au www.healthinformatics.unimelb.edu.au

2. Digital health and analog humans
- from 2000 to 2040
– The story of digital transformation in healthcare
– Where are the human actors in this story?
– New roles and responsibilities of patients and citizens
– New roles and responsibilities of every healthcare professional
– New roles and responsibilities of health information specialists
– How can health information science educators and researchers respond?
2

3. Digital health: what are we talking about?
Digital health is a popular and convenient way to
convey the changes that new technologies are
bringing to healthcare in the twenty-first century.
Digital health means many things to many people.
Digital health is not (yet) a scientific discipline.
3
• an improvement in the way healthcare provision is
conceived and delivered by healthcare providers
• through the use of information and communication
technologies
• to monitor and improve the wellbeing and health
of patients
AND
• to empower patients in the management of their
health and that of their families
Source: Iyawa GE, Herselman M, Botha A (2016) Digital Health Innovation Ecosystems:
From Systematic Literature Review to Conceptual Framework. International Conference
on ENTERprise Information Systems/International Conference on Project
MANagement/International Conference on Health and Social Care Information Systems
and Technologies, CENTERIS/ProjMAN / HCist 2016 100:244-252.
doi:10.1016/j.procs.2016.09.149
Historically, the diverse communities working in digital health
—including government stakeholders, technologists, clinicians,
implementers, network operators, researchers, donors—
have lacked a mutually understandable language
with which to assess and articulate functionality.
Source: WHO. 2018. Classification of Digital Health Interventions v1.0. WHO/RHR/19.06
https://www.who.int/reproductivehealth/publications/mhealth/classification-digital-health-
interventions/en/

4. Related terms & component parts
Connected health
E-health
Four (or five) ‘P’ health
(participatory, personalised, precision, predictive, preventive)
Health 2.0 (or 3.0)
Health self-tracking
Internet of health things
M-health
Online health
Telehealth
Virtual health
Wearable health
Wireless health …. etc.
4
Access sharing
Apps and sensors
Artificial intelligence
Bioethics
Blockchain
Cloud computing
Cybersecurity
Data analytics
Decision support
Disease surveillance
Gamification
Health promotion
Health records
Imaging
Information m/ s/ t
Interoperability
Knowledge translation
Machine learning
Omics
Organisational learning
Platforms
Social media
Plus, instead of ‘health’, substitute the name of your speciality,
e.g. e-endocrinology, m-midwifery, tele-traumatology.

5. Digital health:
not all new
The term ‘digital health’ entered the research literature
in the 1990s to broadly characterise the impact of
Internet-connected information and communication
technologies on health care.
5
Example 1: Frank, S. R., Williams, J. R., & Veiel, E. L. (2000). Digital health care:
where health care, information technology, and the Internet converge. Managed care
quarterly, 8(3), 37-47. PMID:11184348
Frank SR, Williams JR, Veiel EL (2000) Digital health care: where health care, information
technology, and the Internet converge. Manag Care Q 8 (3):37-47. …
…
…
Example 2: Nicholas, D., Huntington,
P., & Homewood, J. (2003). Assessing used
content across five digital health
information services using transaction log
files. Journal of information science, 29(6),
499-515.
doi.org/10.1177/0165551503296007

6. Digital life is ahead of digital health

7. Tech players: big new
business opportunities
7
https://www.curvetomorrow.com.au/
www.theverge.com/2019/1/3/18166673/technology-health-care-amazon-apple-uber-alphabet-google-verily

8. 8
https://www.safetyandquality.gov.au/our-work/e-health-safety
Service providers:
quality & safety
Software as a Medical Device (SaMD) regulation
in Australia
The regulation of medical devices is risk-based. This means that the
level of scrutiny and oversight by the TGA will vary according to the
level of risk that the product represents to the patient or healthcare
professional using it.
The current regulations do not adequately capture all SaMD under the
rules for this risk classification. The potential risks arising from SaMD
products can be low, medium or high depending on the intended
purpose of the SaMD; however, at the present time many SaMD
products are classified as low risk even though the potential risk for
users may be higher. The TGA will soon be consulting on changes to
the regulations to address this issue.
SaMD products must be included on the Australian Register of
Therapeutic Goods (ARTG) before they are supplied in Australia.
The therapeutic goods legislation requires manufacturers of SaMD
products (unless they are Class 1 - the lowest risk classification) to
obtain Conformity Assessment certification to allow inclusion in the
ARTG.
https://www.tga.gov.au/regulation-software-medical-device

9. Public policy
makers:
sustainability
Canada Health Infoway
https://infoway-
inforoute.ca/en/component/edocman/resources/i-infoway-i-
corporate/business-plans/3654-summary-corporate-plan-
2019-2020?Itemid=101
European Commission Ehealth
Action Plan
https://ec.europa.eu/digital-single-market/en/news/ehealth-
action-plan-2012-2020-innovative-healthcare-21st-century
UK National Health Service Long
Term Plan: Chapter 5
https://www.longtermplan.nhs.uk/online-version/chapter-5-
digitally-enabled-care-will-go-mainstream-across-the-nhs/
US Office of the National Coordinator
for Health Information Technology
https://infoway-
inforoute.ca/en/component/edocman/resources/i-infoway-i-
corporate/business-plans/3654-summary-corporate-plan-
2019-2020?Itemid=101
Strategic priorities
1.Health information that is available
whenever and wherever it is needed
2.Health information that can be
exchanged securely
3.High-quality data with a commonly
understood meaning that can be used with
confidence
4.Better availability and access to
prescriptions and medicines
information
5.Digitally-enabled models of care that
improve accessibility, quality, safety and
efficiency
6.A workforce confidently using digital
health technologies to deliver health and
care
7.A thriving digital health industry
delivering world-class innovation
www.digitalhealth.gov.au

10. Representations
of digital health:
Where are the
humans?
Naturalisation
10
Belliger, A., & Krieger, D. J. (2018). The Digital Transformation of Healthcare. In Knowledge Management in Digital Change (pp. 311-326). Springer, Cham.

11. Innovation
11
Van Winkle, B., Solad, Y., Vaswani, N., & Rosner, B. I. (2019). Navigating the Digital Health Ecosystem to Bridge the Gap from Innovation to
Transformation: A NODE. Health Perspective on Digital Evidence. Digital Biomarkers, 3(2), 83-91.

12. Acceleration
12
https://www2.deloitte.com/us/en/insights/industry/health-care/forces-of-change-health-care.html

13. Hyperconnection
https://www.accenture.com/us-en/insight-infrastructure-internet-of-thinking

14. Revolution
https://www.project-syndicate.org/commentary/digital-revolution-impact-on-wellbeing-by-michael-spence-2019-06
14

15. Disruption
‘Digital transformation and disruptive innovation
describe the comprehensive reorientation of an
industry including its business models due to the
coming of age of digital technologies: the
digitization of products, services, and processes.
It is expected that digital transformation of the
health care sector will be as disruptive as that
seen already in other industries.
Despite new technologies being constantly
introduced, this change has yet to materialize … ‘
400 products from 100 leading start-up, life science, and technology companies, analysed in Herrmann M, Boehme P,
Mondritzki T, Ehlers JP, Kavadias S, Truebel H. Digital Transformation and Disruption of the Health Care Sector: Internet-Based
Observational Study J Med Internet Res 2018;20(3):e104 DOI: 10.2196/jmir.9498
15

16. Experienceshowsthatdigitalhealthisnotplug-and-play!
Howdohumanactorsneedtoact,tomakeitwork?
Patients,clinicians,thehealthinformationworkforce….
x

17. Patients as actors
Individual differences, at all ages and life stages
Conditions vary – accidental, acute, chronic,
disabling, infectious, inherited
Activity is a good predictor of health
Before digital health
• Minimal access to data, information or knowledge
• Dependent relationships with clinicians
17https://www.nature.com/articles/sj.bdj.2018.160
https://www.kingsfund.org.uk/publications/supporting-people-manage-their-health

18. Digital health: patients need to make consumer choices
18
Borda, A, Gilbert, C., Gray, K, & Prabhu, D. (2018). Consumer Wearable Information and Health Self Management by Older
Adults. Telehealth for Our Ageing Society: Selected Papers from Global Telehealth 2017, 246, 42-61.

19. Digital health: patients need to take control
of generating and sharing their data
a new information practice: a shift from a ‘push’ method (a referral or discharge letter) to a
‘pull’ method
a clinician can download from a patient’s MyHR information that may not be curated and
thus may not be pertinent to that clinician – may not even be up-to-date
contrasts with a management and care plan, which is designed to be used in team-based
care of a particular type (e.g. aged care, chronic disease, mental health) and to include
information relevant to those providing care
“a glorified dropbox”; a breach of contextual integrity? 19
Kariotis, T., Prictor, M., Chang, S., & Gray, K. (2019). Evaluating the Contextual Integrity of Australia's My Health Record. Studies in health technology and informatics, 265, 213-218.
Dimaguila, G. L., Gray, K., & Merolli, M. (2019). Measuring the outcomes of using person-generated health data: a case study of developing a PROM item bank. BMJ health & care informatics, 26(1), e100070.
Patient-reported outcome measures (PROMs) allow patients to self-report the
status of their health condition or experience independently.
As such, PROMs enable patients to contribute to more precise evaluation of the
effects of various health interventions, and they contribute to improving the
evidence base in various areas of clinical care.
PROMs offer a standardised approach to evaluating and improving healthcare
services, and this is highlighted by key national projects to develop suites of PROMs
for various health conditions in the USA, Europe and Australia.
A key area for PROMs to contribute in building the evidence base is in
understanding the effects of using person-generated health data (PGHD). PGHD are
created, recorded and analysed by people, who are monitoring their health outside
of a clinical care setting.
PGHD include health, wellness and other biometric data produced from
technologies such as mobile applications, activity tracking devices and simulated
rehabilitation technologies.

20. Digital health: patients need to
have a say in the research agenda
20Borda, A., Gray, K., and Fu, Y. [2019 in press]. Research Data Management in Health and Biomedical Citizen Science: Practices and Prospects JAMIA Open. DOI10.1093/jamiaopen/ooz052
Lopez-Campos, G., Kiossoglou, P., Borda, A., Hawthorne, C., Gray, K., & Verspoor, K. (2019). Characterizing the Scope of Exposome Research Through Topic Modeling and Ontology Analysis. Studies in health technology and informatics, 264, 1530-1531.
https://crowdcare.unimelb.edu.au/ ; Lopez-Campos, G., Merolli, M., & Martín-Sánchez, F. (2017). Biomedical Informatics and the Digital Component of the Exposome. Studies in health technology and informatics, 245, 496-500.

21. Clinical healthcare professionals as actors
Doctors, nurses and 20+ other specialised roles
Formally trained, legally licensed to practice
Professional code of conduct and duty of care
Before digital:
• Learning through traineeships, tutors, textbooks
• Trusted, recognised authority
21
https://www.ehealth.gov.hk/en/publicity_promotion/ehealth_news_14/six_new_groups_access.html
https://www.quora.com/Why-do-doctors-these-days-always-wear-a-stethoscope-around-their-neck-It-seems-like-it-is-just-a-status-symbol-Years-ago-they-carried-their-stethoscopes-neatly-tucked-away-in-a-coat-pocket

22. Digital health: clinicians need to
work within new models of care
22
https://www.health.org.uk/publications/the-patient-will-see-you-now

23. Digital health: clinicians need to rely on the quality
of real-world data and recycled data
23
Abdolkhani, R., Gray, K., Borda, A., & DeSouza, R. (2019). Patient-generated health data management and quality challenges in remote patient monitoring. JAMIA Open. https://doi.org/10.1093/jamiaopen/ooz036
Henley-Smith, S., Boyle, D., & Gray, K. (2019). Improving a Secondary Use Health Data Warehouse: Proposing a Multi-Level Data Quality Framework. eGEMs, 7(1).

24. Digital health: clinicians need to partner
with computers
https://aihealthalliance.org/
https://www.online-sciences.com/tag/automation-in-medicine/
24https://www.online-sciences.com/tag/automation-in-medicine/

25. Health information specialists as actors
Diverse groups and origins:
medical libraries, government documents, IT
infrastructure, patient records, clinical trials data …
Agency, ‘providing a service for other groups’
Before digital:
• Distinct tribes and territories
• Curators, gatekeepers of large volumes of paper
25https://www.learn4good.com/alliedhealth/medical_librarian_careers.htm

26. Digital health: Health librarians need to reinvent
their roles
26
65+ position titles among 238 respondents:
5 position titles in almost half the responses: Librarian, Library
manager, Library technician, Senior librarian, and Medical
librarian.
12 newer titles reflect the digital environment: Data Officer, Digital
Content Coordinator, E-health Facilitator, Electronic Resources
Librarian, Electronic Services or E-Services Librarian, Health
Information Coordinator, Knowledge Services Advisor (or
Manager), Library and Literacy Project Officer, Systems Educator,
and Systems Support Librarian.
Other specialist role titles: Consumer Health information
Coordinator, (Medical or Senior) Research Librarian, Research
Information Specialist.
https://circulatingnow.nlm.nih.gov/2018/06/24/nlm-in-pictures-read-it-this-summer/
Gilbert, C., Gray, K., Butler-Henderson, K., & Ritchie, A. (2019, June). Digital health and professional identity in Australian health libraries: Evidence from the 2018
Australian health information workforce census. Paper presented at the 10th International Evidence Based Library and Information Practice Conference, Glasgow.
https://www.utas.edu.au/health/projects/hiwcensus

27. Digital health: Health informaticians need to
clarify their roles
310 different role titles among 420 respondents:
most common titles (reported by 25.8%):
(Clinical) Business Analyst, Chief Clinical
Information Officer, Chief Data Scientist, Chief
Medical Information Officer, Chief Nursing
Information Officer, Clinical Application Specialist,
Clinical Informaticist, Clinical Informatics Manager,
Consultant, Data Analyst, Data Manager, Digital
Health Manager, Digital Health Officer, Director,
EMR Analyst, Enterprise Architect, Health
Information Manager, Health Information Officer,
Implementation Consultant, Project Manager, and
Research Fellow.
27
https://www.healthinformaticscertification.com/
Butler-Henderson, K., Gray, K., Pearce, C., Ritchie, A., Brophy, J., Schaper, L., Bennett, V., & Ryan, A. (2019). Exploring the health informatics occupational group in the 2018 Australian Health Information Workforce Census (pp.44-50) In E. Cummings, M. Merolli, & L.
Schaper, Eds., Digital Health: Changing the Way Healthcare is Conceptualised and Delivered. (Studies in Health Technology and Informatics, vol. 266). Amsterdam, Netherlands: IOS Press. ISBN 9781643680064. DOI: 10.3233/SHTI190771
https://www.utas.edu.au/health/projects/hiwcensus

28. Digital health: Health information technologists
need to professionalise their roles
Only half (48.5%) of respondents in the health information
technologist group possess a specialised university
qualification. This puts them in the middle of a spectrum.
The health information management and health librarian
disciplines are specialist disciplines where a high number of
workers possess a specialist university qualification (93.8% and
95.3% respectively).
At the other end, 73.1% of respondents from the health
informatics discipline do not hold any relevant qualification,
although nearly a quarter of that group (23.9%) maintain a
clinical or health professional registration through Australian
and New Zealand accreditation regulations.
28
among 227 respondents
Butler-Henderson, K., Gray, K., Day, K., & Grainger, R. (2019 under review) Defining the Health Information Technology discipline: results
from the 2018 Australian and New Zealand censuses
https://www.utas.edu.au/health/projects/hiwcensus

29. There is growing global consensus about the role of
digital health in healthcare systems
https://www.who.int/reproductivehealth/publications/m
health/classification-digital-health-interventions/en/

30. Digital health brings sophisticated work-arounds for
the activity, authority & agency of analog humans
30https://www.semic.de/en/ai/semic-health
https://venturebeat.com/2018/11/26/what-moxi-the-robot-is-learning-from-nurses-in-texas/
https://hbr.org/2018/03/how-ai-is-taking-the-scut-work-out-of-health-care
https://www.gov.uk/government/news/health-and-social-care-secretary-bans-fax-machines-in-nhs
FDA approved 2018
Trained at Texas Health Dallas, 2018
Once-hyped technology such as electronic health records
have become part of the problem and added to – rather than
mitigated – overload and burnout.
We need to rebuild confidence in the promise of technology
to free up provider time and enhance care delivery.
“Through a combination of machine learning and business-
process outsourcing that has automated the categorizing of
faxes, Athena Health in 2017 alone managed to eliminate
over 3 million hours of work.”

31. … but we remain deeply concerned with the challenges
of engaging analog humans in digital health
31
https://topol.hee.nhs.uk/wp-content/uploads/HEE-Topol-Review-2019.pdf
Calls for action to:
• develop frameworks that align health systems/governance and
health workforce policy/planning,
• explore the effects of changing skill mixes and competencies
across sectors and occupational groups,
• map how education and health workforce governance can be
better integrated,
• analyse the impact of health workforce mobility on health
systems,
• optimise the use of international/EU, national and regional
health workforce data and monitoring,
• build capacity for policy implementation.
Kuhlmann, E., Batenburg, R., Wismar, M., Dussault, G., Maier, C. B., Glinos, I. A., ... & Groenewegen, P. P. (2018). A call for action to
establish a research agenda for building a future health workforce in Europe. Health research policy and systems, 16(1), 52.
The levels of digital literacy, the workforce’s awareness of the required capability, access
to training and support, and skills to enable patients and citizens to improve health
and wellbeing through technology will all need to be improved, as a fundamental shift in
the balance of skills in the workforce takes place over the next two decades.

32. https://medicalfuturist.com/ https://www.twenty20.com/photos/8c423243-c295-4fb6-b7b7-e25f03739be5
32
What will human work
in digital health
look like in 2040?
Whose interests is digital health designed to serve?
How do those human actors experience and evaluate
the benefits to them?
What is your research contributing to addressing
these questions?

33. Thank you
kgray@unimelb.edu.au
www.healthinformatics.unimelb.edu.au