Digital + Public + Health after 2020

I have had an opportunity the last few weeks to participate in a workshop on digital technologies for public health organised by ECDC. Luís Lapão presented some wonderful framing in thinking about digital public health, within the PHIRI collaboration (EU project Population Health Information Research Infrastructure). It has made me think about the intersection between digital transformation ~ public health ~ health research ~ health policy-making.

Public health has not received as much attention as health care in the discussions of digital transformation of the health sector. In 2017, WHO Europe Regional Director referred to the linkage between digital health and public health as a "beautiful marriage" that needs to start with a political committment. Following this European Public Health Association established the digital helath section and stressed that digital public health work needs to be concretely planned, implemented and evaluated. Other parts of the world have been marrying public health and digital transformation as well.

Here's four things that we need to reflect on.

1. Digital transformation and public health practice often still talk past each other, let's align them

Often, discussion of digital transformation in health still remains at high level, focused on universal health coverage, and less on public health and policies targeted at health and well-being of populations through the lifecourse. WHO's digital health strategy 2020-2025 still looks at building basic building blocks of a digital health environment, but I wonder how the global digital health strategy would look now, post 2020.

The pandemic has stressed governments and societies to the brink. Health systems' resources are spread thinly to cover basic services and public health functions, and must now adapt their acute emergency response work and move to longer-term management of COVID-19 as part of national health system challenges.

So really, health-in-all government policies are a matter of maintaining equitable resilience of the health system and of the society. We also cannot ignore the important interplay between environment, animal and human health, and the demands this will put on our research, information and knowledge translation systems.

The priorities of digital transformation therefore need to be derived from highest priorities of public health and of the health information systems that inform health policy-making. Let's advocate for the digital transformation of public health and health information systems as loudly as for that of health care delivery.

2. Digital public health needs to amalgamate all practices that can help achieve public health impact

Digital health practice has not been great at documenting, evaluating and iterating on digital services and implementation. A public health approach to digital transformation adoption must be underpinned by:

• implementation research and monitoring and evaluation (M&E) of interventions and projects
• feedback into health system and outbreak response, for a nimbler and transparent decision-making and policy management. I wrote a little bit about this when the WHO pandemic intelligence hub was announced

At the same time, public health intelligence, systems, and tools need to evolve to cover new challenges. One of the biggest ones of that past year has been the fact that the success of epidemic management measures, including public health and social measures, depends on cooperation and compliance of the people and communities. Not only do the analytics need to change (better monitoring and evaluations of measures, and infodemic management), the practices of decision-making and response need to adapt as well.

And then I think there's the area of evidence assessment for decision-making - digital health hasn't been paying enough attention to evidence appraisal, synthesis of knowledge and knowledge representation outside clinical settings. We need to take a closer look at how to speed up evidence assessment and access to reliable evidence, both for systematic living reviews, as well as "surge response" during an epidemic caused by a new pathogen.

3. Humans are still at the center of (digital) (public) health

Over the years, we've become quite good in developing personalised medicine, and adopting concepts from complexity science like digital twins. During the COVID-19 pandemic, digital tools have been more easily used for care delivery (telemedicine), than in aspects of epidemic response. I think one of the reasons of this is that humans are at the heart of public health and emergency response. Ultimately, humans are contributors, managers and users of the data.

To be better at digital public health, digital practice needs to get even better at recognizing "public health" in this practice. Often, decisions must be made on best available evidence where clear data or evidence are not available and are connected by expert judgement. Other times, low public acceptance of a tool, or a perception of an epidemic control measure can derail its usefulness - as we have seen with low adoption of COVID-19 proximity tracing apps in Europe, or just about any other public health ans social measure that has been challenged by misinformation, mistrust and information travelling internationally, comparing countries at superficial levels.

We cannot easily address all these challenges, but I think that putting the human at the center of digital public health will orient us towards the best possible use of digital technologies for biggest public health impact.

• we need to practice human-centered design of tools and processes that enable health information flows
• we need to practice participatory design, implementation and evaluation of digital health interventions in communities and populations. For example, we should be doing more of this - Simões, A. S., et al. "Participatory implementation of an antibiotic stewardship programme supported by an innovative surveillance and clinical decision-support system." Journal of Hospital Infection 100.3 (2018): 257-264.
• we need to use technology and tools to help us wade through masses of data points, and to more seamlessly exchange information
• we need to use technology to enable evidence review and decisions closer to the points of decision-making authority - in an outbreak, these are people integrating outbreak investigation, community engagement and health system response. I wrote about the importance of the human-led integrated analytics for rapid decisionmaking a few months ago - see integrated multidisciplinary outbreak analytics (IMOA)

4. Digital Public Health needs to evolve and grow out of the post 2020 change

We are practicing public health and digital health in a permanently changed health policy ecosystem. Digital Public Health must serve the needs of policy-makers, professionals, and people broadly. We will need to respond to a variety of needs:

• The main question for policy-makers for a while still will be how countries can develop resilience to live in a COVID-19 endemic world, while addressing inequalities and other tensions caused by the pandemic. Nimble localised outbreak management would require near real time and granular analytics at local level and new approaches to monitoring, and digital technologies can respond to this need.
• Surveillance and preparedness and response will need to serve new insights – crowdsourced practices should be explored and adopted either for adding to routine capacities or for preparation of surge capacities for emergency response; participatory design, management and evaluation of surveillance, and other programmes and interventions should become part of the toolbox; health authorities need to embrace the open movement (open science, data, etc) as a complement to existing practices.
• Over time, we will have to deal with a resurfaced tension with citizens over the use of personal health data that was exceptionally authorized for emergencies. Practices that we've tried and adopted will need to be discussed and incororpated into routine. That means that we will need a set of goals and principles for how we do want to practice digital public health.
• Integrated health information exchange across borders will only be feasible with investment and support at subnational and national levels first. While we have been advocating for strenghtened health information systems for years, this is the time to really follow through.

So we need to invest in digital public health practice, services and systems to answer questions like:

• what is needed to do close-to-real-time and more reliable detection of signals and threats
• what is needed for close-to-real time risk assessment
• what is needed for close-to-real-time and living evidence assessment (across all grades of evidence)
• what is needed to foster resilient digital health ecosystem & surveillance system that meet the needs of health policymaking, and resilient people and communities

Will digital + public + health evolve?