Tan 2023 Digitalsolutionstopublihealthissues

Digital Solutions to Public Health Issues

Si Ying Tan, National University of Singapore and Jeremy Fung Yen Lim, National University of
Singapore
https://doi.org/10.1093/acrefore/9780190632366.013.329
Published online: 22 February 2023
Summary
Digital health technology has been adopted rapidly by countries as tools to promote good public health outcomes
over the last decade. The COVID-19 pandemic that occurred since November 2019 has further accelerated the
salience and relevance of digital health technology in tackling public health issues as countries start to implement
movement restriction policies that pose a challenge to the physical delivery of healthcare services. Unarguably, the
pandemic has elevated the significances of digital solutions to public health issues, which include improving access
to an increased range of health services and the potential of cost-saving, maximizing population-wide health
impacts through behavioral modifications, and controlling and managing public health emergencies. In general,
digital technology in public health has three major applications—monitoring, decision support, and education.
Monitoring is especially relevant in the context of effective disease screening and pandemic surveillance, decision
support applies to the promotion of behavior modifications and resource optimization, while education serves to
improve population-level health awareness and knowledge. Despite the promises of digital solutions to address
various public health issues, there are unintended consequences that could arise consequent to their widespread
applications, resulting in governance challenges and ethical issues in their applications, such as data privacy and
erosion of trust, safety, cybersecurity, algorithmic bias, liability, autonomy, and social justice. To reap tangible
benefits and positive impacts from large-scale deployment of various digital health solutions, countries need to
anchor their national digital health policies or strategies by considering not only their benefits and applications, but
also various governance challenges and ethical issues that could ensue during their implementations.
Keywords: digital technology, public health, applications, monitoring, decision support, education, governance, ethics
Subjects: Biostatistics and Data
Introduction
The application of digital health technology has seen a rapid rise in the past decade and this trend
has been further accelerated during the COVID-19 pandemic. Digital health technologies
commonly applied in the public health arena include (a) health-related mobile apps, (b) digital
therapeutics and digital care products, (c) wearables, and (d) digital diagnostics and digital
biomarkers for a variety of objectives such as personal health tracking, patient education and
health management, population-level health prevention, and supporting large-scale clinical
trials (Aitken & Nass, 2021; Budd et al., 2020).
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date: 27 February 2023
According to a recent study on digital health trends, heath-related mobile apps available for
downloads in top app stores—including wellness apps and disease-specific apps—have
surpassed 350,000 by 2020, with more than 90,000 apps added just in 2020 itself (Aitken & Nass,
2021). Besides health-related mobile apps, the use of digital therapeutics and digital care
products is also on the rise, with more than 250 such products identified, of which 150 are
commercially available in the market (Aitken & Nass, 2021). Digital therapeutics and digital care
products are advanced digital health tools that incorporate software to treat, prevent, or manage
specific medical conditions, and normally require market authorization from regulatory bodies
(Aitken & Nass, 2021). In addition, wearables have also been used extensively for health
monitoring purposes recording indicators such as steps taken, distance traveled, heart rate, and
calories burned at the individual level. As of the second quarter of 2021, there were 384 wearable
devices available in the market (Aitken & Nass, 2021). Digital diagnostic tools and digital
biomarkers have also been employed in decentralized hybrid clinical trials that enable data to be
recorded at the patients’ homes, thereby reducing burdens for both investigators and patients in
data collection (Aitken & Nass, 2021).
The COVID-19 pandemic has accelerated the adoption of digital health technologies across the
world and elevated their importance as critical tools for effective public health responses in many
countries. Various digital health tools have propelled swift public health actions from the
governments in their efforts to contain and break the chain of disease transmission. These have
been conducted through epidemiological surveillance using survey apps to report symptoms, data
extraction and visualization to prepare a data dashboard, rapid case identification through
connected diagnostic devices or wearables to facilitate diagnosis, interruption of community
transmission through contact tracing apps powered by Bluetooth technology, facilitating public
communication through social media platforms, and streamlining clinical care by rolling out
telemedicine (Budd et al., 2020).
This article aims to discuss the use and applications of digital health solutions in public health,
and shed light on several governance and ethical challenges that need to be addressed. The three
significances or rationales of digital solutions to public health issues and the three major
applications of digital solutions in public health are highlighted, while seven governance and
ethical challenges involved in the deployment of digital heath solutions are raised. The
conclusion summarizes key lessons learned and policy recommendations for various actors in the
digital health ecosystem.
Some Examples of Digital Solutions to Public Health Issues
Improving Access to an Increased Range of Health Services and the Potential of

Cost-Saving
Digital health solutions hold the promise to bridge health inequity by expanding the range of
health services to a wider population, be it in high-income or low-income settings (Rahimi,
2019). In particular, a review on mobile health—which is an important domain of digital health—
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has shown to result in substantial impacts in low- and middle-income countries by improving
treatment adherence and appointment compliance among the patients, as well as supporting data
gathering and the development of support networks among the health workers (Hall et al., 2014).
In terms of cost, the question of whether digital health solutions will increase healthcare cost due
to their rising demand in meeting previously unmet needs, or reduce overall healthcare
expenditures due to the lower operational costs, is debatable (Rahimi, 2019). However,
preliminary evidence on the use of digital health tools to facilitate the recovery of specific clinical
conditions such as cardiovascular diseases have shown potential for cost-saving (Bhardwaj et al.,
2021; Jiang et al., 2019). A systematic review on the use of digital health interventions in the
management of cardiovascular diseases reported an improvement in quality-adjusted life-year
(QALY) in 43% of the studies as compared to standard care (Jiang et al., 2019). Another simulation
study that examined the use of smartphone application, smartwatch, and wireless blood pressure
monitor to support medication adherence, patient education, vital signs monitoring, and care
coordination in acute myocardial infraction recovery had shown that when this intervention was
delivered along with standard care, it resulted in significant cost-saving and improved QALY
(Bhardwaj et al., 2021).
Maximizing Population-Wide Health Impacts Through Behavioral Modifications

Through customized intervention and personalized messaging, digital health tools and
interventions can target behavioral changes at the individual level to reap population-wide health
impacts. A bibliometric analysis on the use of digital health technology to change health behavior
reported that digital technology–enabled behavioral change interventions aimed at promoting
physical activity and dietary change have seen a steep rise since 2001 (Taj et al., 2019).
Digital health interventions delivered via mobile phone apps have shown to be effective in
managing a range of acute and chronic conditions by promoting patient self-management and
behavioral change, and have led to better physical and mental health outcomes (Willems et al.,
2021). Through digital phenotyping that primarily employs passive data collection such as a
smartphone capturing a person’s physical location, individual activity, voice, and speech, as well
as a person’s interaction with their mobile device through typing and scrolling, digital data can be
gathered to understand and predict behavioral health outcomes of interest (Marsch, 2021).
Furthermore, digital segmentation, which is based on the use of digital technology behavior to
sort and reach the right audience in a targeted manner by predicting their engagement with
online advertisement and behavioral change campaigns, has been demonstrated to be quite
successful in health behavior modifications among the youth and young adults (Evans et al.,
2019).
Controlling and Managing Public Health Emergencies

The importance of digital health solutions in controlling and managing public health
emergencies has been elevated since the COVID-19 pandemic that started in November 2019.
Since the start of the pandemic in December 2019, various digital health solutions have been
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deployed. These range from artificial intelligence for surveillance, digital platforms for
communication and data management, digital structural screening, and the applications of
internet of things to respond to different situational challenges during the pandemic (Budd et al.,
2020; Gunasekeran et al., 2021; Willems et al., 2021). To effectively curb virus transmission, many
countries have designed and launched their own national contact tracing apps to enable more
effective surveillance to support social distancing guidelines, to streamline the public health
protocols for quarantine/isolation, and to detect infection clusters (Budd et al., 2020). Clinically, a
comprehensive digital health management system that includes the use of telemedicine or virtual
conferencing to monitor patients with mild symptoms recovering at home would allow
healthcare professionals to better respond to the evolving needs of care management during the
pandemic (Anthony, 2021). Besides, a comprehensive digital health management system would
also allow the healthcare workers to escalate protocol remotely if a patient’s symptoms worsen
and require acute management in a hospital setting (Willems et al., 2021).
Conceptual Framework: The Three Major Applications of Digital Solutions

to Public Health
Digital technology has three major applications in facilitating public health solutions—
monitoring, decision support, and education. The foremost role of digital solutions is monitoring
population health to facilitate effective disease screening and surveillance. As the COVID-19
pandemic has shown, digital solutions are effective tools for pandemic control. Apart from this,
digital solutions play a major role in decision support for clinicians, researchers, and
policymakers to dictate public health priorities and optimize resource allocation. Third, digital
solutions function as powerful educational tools to impart knowledge and promote awareness
among the citizens to improve public health outcomes. These three roles essentially provide
information to feedback to one another, as Figure 1 illustrates.
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Figure 1. Three major roles of digital solutions to public health issues.
Monitoring: Effective Disease Screening and Pandemic Control

The foremost benefit of digital health technology is to promote effective screening of diseases in
a timely manner. In the recent years, telemedicine has emerged as a reliable tool to provide
healthcare services and consultation remotely. It has advanced from the use of telephone calls
and short message services or emails, to digital communications that enable virtual diagnosis
(Cahn et al., 2018; Dorsey & Topol, 2016). This advancement allows remote monitoring of
patients, improves administration and management of healthcare, and greatly reduces the need
for individuals to physically visit clinics when their health concerns can be managed via virtual
consultations (Mitchell & Kan, 2019; Senbekov et al., 2020). During the COVID-19 pandemic,
telemedicine has helped to reduce the possibility of disease transmission by allowing healthcare
providers to remotely look after individuals who are in quarantine (Senbekov et al., 2020).
Telemedicine was also shown to benefit patients with chronic illnesses and required close
monitoring of their conditions (Orozco-Beltran et al., 2017; Wootton, 2012; Zhang et al., 2021).
Telemedicine is a digital revolution that changes our mode of healthcare provision during the
COVID-19 pandemic. Before the pandemic, the healthcare industry was predominantly structured
based on the conventional mode of in-person integrations between patients and clinicians.
However, during the disease outbreak, increased physical contact facilitated the spread of virus
and was thus minimized. The use of telemedicine in this scenario allows the delivery of care
services through minimal physical interaction between the healthcare providers and the patients
(Keesara et al., 2020; Mann et al., 2020; Monaghesh & Hajizadeh, 2020).
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With the integration of digital technologies to the health system, diseases can be screened by
applying digital biomarkers—objective measures of health or biological response collected by
digital devices—to determine one’s physiological responses to therapeutic intervention.
Nowadays, wearable devices (such as finger‐worn sensors and biometric skin patches) and
smartphone apps (such as cognitive assessment and typing behavior) are able to passively
measure certain physiological changes in the body without requiring the patients to wear any
sensors. Such screening processes can be carried out either actively or passively by the users,
enabling more frequent, objective, and sensitive measures of disease progression (Dockendorf et
al., 2021).
A study conducted by Merck and Koneksa Health showed that the measurement of heart rate and
blood pressure changes via mobile health was comparable to standard in‐clinic measures and
provided enough sensitivity to detect treatment differences. This breakthrough suggests that
applying digital devices for screening can provide meaningful information regarding an
individual’s health condition (Dockendorf et al., 2021; Huang et al., 2020).
Digital monitoring can also contribute to disease management of chronic illnesses such as
diabetes and heart diseases. Digital sensors and smart devices enable long-term and remote
monitoring, thereby holding the promise to either prevent or reduce the chances of the
occurrence of life-threatening conditions such as stroke and heart attack (Alwashmi, 2020;
Senbekov et al., 2020). AliveCor’s smartphone electrocardiogram is the first Food and Drug
Administration (FDA)–approved digital health sensor that can be used to detect atrial fibrillation.
Other than smartphones, this application can also be incorporated into Apple Watch, further
enhancing its monitoring capacity (Mesko, 2018). BlueStar is another FDA-approved application
that can act as a diabetes management platform. Patients can adjust their insulin dosing by using
the insulin calculator on the platform based on physicians’ prescriptions (Sharma et al., 2018).
Essentially, digital health devices can measure and record a wide range of health parameters such
as the user’s vital signs, physical activities, dietary intake, energy expenditure, and glucose level.
This wealth of information is not only helpful for patients’ self-monitoring and monitoring from
physicians, it can also be fed into the health system to identify public health challenges and
service gaps (Huat et al., 2019).
Digital monitoring also reduces the barrier for individuals inclined to seek help for mental health
issues. Besides improving the accessibility to consultation and counseling, it could potentially
reduce the stress and anxiety of affected individuals (Cao et al., 2020). For instance, users
reported satisfaction and positive attitudes toward the use of digital health in addressing their
mental health concerns as they felt that such an approach provided them more privacy and
encouraged them to respond truthfully as compared to physical consultation (Liem et al., 2020).
From a macro perspective, digital health solutions have proven to be indispensable in the control
of the COVID-19 pandemic. Surveillance provides a big picture of the disease outbreak. However,
within the community, contact tracing serves as a critical step in containing the spread of the
infectious agent. It identifies the disease carriers as well as individuals who have been in contact
with the carrier. Thus, this approach serves as a primary measure of containment that terminates
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the chain of human-to-human transmission. As most epidemic/pandemic-causing infectious

agents are highly transmissible, with our existing population density and fluidity, traditional
paper-based contact tracing could not keep up with the transmission rate. However, with the help
of technologies such as smartphones, Global Positioning System, and Bluetooth, digitalized
contact tracing has contributed significantly to disease containment. For example, in Singapore,
the use of Bluetooth technology in the mobile app has been used to identify individuals who have
been in close contact with persons who have been diagnosed with COVID-19. This allows the
authority to identify potential disease clusters and isolate potential cases as early as possible
(Alwashmi, 2020; Lai et al., 2021; Tom-Aba et al., 2018). Similar applications have been developed
and adopted in countries such as Australia, New Zealand, and France (Horstmann et al., 2021;
Sharma et al., 2020; Touzani et al., 2021; Tretiakov & Hunter, 2020).
Other than identifying potentially infected individuals, contact tracing platforms can also be used
to identify potential transmission hotspots and assess the effectiveness of public health
interventions such as movement restrictions and mass vaccination programs (Budd et al., 2020).
Moreover, contact tracing platforms are often equipped with automatic alert systems that send
reminders or message alerts to those likely to be ignorant about the lockdowns or movement
restrictions during the pandemic (Radanliev et al., 2020).
Decision Support: Promoting Behavior Modifications and Optimizing Resource

Allocation
Many digital health applications are implemented at the health agency level to manage the
population’s health effectively. As health awareness grows and demand for the improvement of
well-being increases among the population, this will inevitably generate a marketplace for health
and fitness wearables. By using mobile apps, biosensor-equipped clothing, and wearable fitness
devices, people can be more actively engaged in the process of changing their current lifestyle in
order to gain more control over their personal health (Greiwe & Nyenhuis, 2020; Ledger, 2014;
Montgomery et al., 2018). At the core of these “smart” devices, the internet of things enables
sensors to power almost any ordinary object in people’s daily lives. The ability for the integration
of this technology into every part of our life demonstrates its potential in changing our behaviors
(Baig et al., 2019; Haghi et al., 2017; Montgomery et al., 2018; Piwek et al., 2016).
For individuals with health concerns, a digital health device serves as a tool to enhance their
health consciousness. For example, it can remind the users about their medication intake, dietary
restrictions, and sleep-wake routines. Most of the devices also provide real-time actionable
feedbacks which users can access and examine. This empowers users by providing greater
understanding of their health conditions, thus enabling them to make better decisions about their
health (Greiwe & Nyenhuis, 2020; Montgomery et al., 2018; Patel et al., 2012; Stone et al., 2020;
Van Hooren et al., 2020). In the longer run, digital wearables may modify certain disease-causing
habits, potentially leading to reduced healthcare costs of chronic diseases such as diabetes,
obesity, and hypertension.
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Behind the interface of the digital health devices, companies are capturing data on the users’
contextual activity, health, and emotional state. The aim is to tie offline data to online behaviours
and connect medical and clinical data with nonmedical behavioural and demographic information
to infer and predict health behaviours and conditions. Simultaneously, predictive analysis using
the existing data generated by the user was used to design a customized feedback mechanism for
the user (de Arriba-Pérez et al., 2016; Gupta, 2015; Hernandez & Zhang, 2017; Montgomery et al.,
2018).
In essence, the use of novel technologies creates a continuous data flow—from the collection of
health information of the users through various devices to receiving that information via various
intelligent communication platforms, clinicians can assess the health conditions of their patient
in real time, allowing them to provide reliable, efficient, and personalized health care to their
patients (Senbekov et al., 2020). Besides enabling two-way communication between physicians
and their patients, these health data can be aggregated for the examination of population health
profiles to facilitate better decision making in the allocation of health resources.
Education: Improving Health Knowledge and Awareness

In the medium to longer term, digital health technology would become a useful tool that health
agencies can leverage to improve the delivery of safe and efficient population-level health
initiatives to enhance health awareness among the citizens. For instance, the Australian
government has launched My Health Record—a secure online summary of key health
information for people and their healthcare providers. Through this one-stop platform, people
can view their digitized health records such as medication records, allergies and diagnoses,
hospital discharge summaries, medical subsidies, and billing information (Makeham, 2019; 2020;
Senbekov et al., 2020).
The use of digital platforms as part of a comprehensive public health intervention is also observed
for other communicable diseases such as human immunodeficiency virus (HIV) and other
sexually transmitted infections (STIs). Digital platforms have been used to educate users about
the importance of protected sex, deliver preexposure prophylaxis education, promote STI/HIV
testing, and accelerate care and treatment for patients (Cao et al., 2020; Jones et al., 2019). Digital
health interventions are especially effective toward the younger population. The appointment of
social media influencers with a large number of followers to advocate for healthy sexual
behaviors allows the message to receive more public attention. This peer-led intervention has
been seen as a persuasive approach for on-campus health promotion and dating apps (Cao et al.,
2020; Fernandez et al., 2019; Forsyth et al., 2018; Lau et al., 2019). Besides, the crowdsourcing
approach can also increase public engagement for health promotion. This digital platform allows
users or participants to be actively involved in the discussion and effectively collect feedback
from the rest of the community (Fitzpatrick et al., 2018; Tang et al., 2018).
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Governance Issues and Ethical Challenges
Data Privacy and Erosion of Trust

One of the most common governance challenges in the implementation of digital health
technology is data privacy. At the health providers’ end, the breach of data privacy is usually a
combination of negligence/human error, malicious intent, or the lack of an ethical framework to
manage these oversights (Agboola et al., 2016; Andanda, 2020; Chernyshev et al., 2018). One of
the most common digital health applications that is vulnerable to data privacy is the electronic
patient record (EPR). The EPR stores longitudinal clinical data, laboratory, and diagnostic test
results across various healthcare facilities, and can be linked through data portals in wide
networks to facilitate clinical decision making, prescription refilling, appointment scheduling,
and public health case reporting, as well as research applications. Hence, the wealth of data that
EPR stores naturally predisposes it to such violations for the purpose of monetization (Birnbaum
et al., 2018). In addition, the lack of robust privacy legislations or frameworks to govern the entire
lifecycle of health data obtained from digital health apps is another common problem that results
in data privacy violation. In spite of the adoption of General Data Protection Regulation in Europe
since 2018, and the prescription on data privacy by the Health Insurance Portability and
Accountability Act in the United States, there remain ambiguities surrounding data access and
data ownership in the healthcare arena. Besides, there are no robust policies surrounding data
destruction in the event that a user uninstalls an app or a manufacturer/developer goes out of
business (Gordon & Stern, 2019).
The issue of lack of prescription on data destruction policies, including how much compensation
that health providers or manufacturers will need to provide to individuals should their data be
sold or repurposed for research use, is very much related to the immortal nature of the digital
health footprint, which has raised longstanding debates about privacy on digital health
information particularly, on genetic data privacy. Genetic data share this quality because the
chain of custody is long, digital copies of genetic data can exist in multiple platforms, and
chances are these data will be used perpetually as there is no set expiration date and no clear
method to destroy these data at the moment (Grande et al., 2020). The immortal nature of genetic
data that had raised debates among bioethicists can be best illustrated by the famous case of
Henrietta Lacks, a black female patient whose cervical cancer cells were taken without her
consent back in the 1950s in the United States. Her cervical cancer cell lines were later shared with
multiple other research laboratories and applied extensively, which fueled key discoveries in
multiple fields including cancer, immunology, infectious diseases, and mostly recently, on the
development of COVID-19 vaccines (Nature, 2020). Genetic data are highly personal data and data
scientists have shown that an individual can easily be identified from a population genetic
database even without personal identifiers (Grande et al., 2020).
At the users’ end, ignorance as well as the lack of awareness on the privacy frameworks of various
digital health applications may also contribute to the violation of data privacy and the erosion of
trust. For instance, when a person downloads a digital health app in their smartphone, he or she
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may be unaware of whether a set of privacy policies or agreements exists in the app. This makes
them incognizant toward the extent of data that they have “authorized” the developers to access,
and whether private information are sold or sent to a third party (Filkins et al., 2016). For
instance, a study analyzing mobile health apps in the United States revealed that 40% of the
applications collected high risk-data that included financial information, full name, health
information, geo-location, date of birth, and zip code (Filkins et al., 2016). Eighty-three percent
of these applications stored their data locally without encryption, and only 50% of these
applications have personal identifiable information encrypted (Filkins et al., 2016). Another study
of diabetes apps for Android smartphones revealed that many diabetes self-monitoring apps
routinely shared users’ information with third parties (Fleming et al., 2020). These are examples
of data privacy breaches that are rampant due to the profitability that developers could gain from
selling these big data to third parties, compounded by the lack of strong enforcement in data
privacy governance.
The above discussed issues concerning data privacy and erosion of trust are similarly observed in
low- and middle-income countries where regulatory mechanisms to govern data privacy are even
more lacking (Gopichandran et al., 2020). In India, the Aadhaar biometric identification system
has been subjected to various litigations due to data privacy breaches including linking digital
health information to the Aadhaar identification system, leaking of its data to private
telecommunication companies, and government websites inadvertently displaying individual
data from the Aadhaar system (Gopichandran et al., 2020). Weak privacy laws and the lack of
capabilities of many low- and middle-income countries to govern digital health data protection
pose a fundamental challenge to the widespread applications of digital health technologies in
those countries.
Safety
Patient well-being and safety are always at the heart of all safety discussions surrounding digital
health applications (Dhingra & Dabas, 2020; Fleming et al., 2020). Many medical information
embedded in the digital health apps may be misinterpreted by patients, especially when they are
acquired from uncredible online resources without guidance from the health workers or
manufacturers who developed the apps (Dhingra & Dabas, 2020). One prominent example is the
various digital health apps developed specifically for diabetes patients. With the mushrooming of
various apps to support diabetes patients ranging from those focusing on nutrition, to physical
activity, to glucose monitoring, to insulin titration, and to insulin delivery, the danger is some of
these apps may cause more harm than benefits without regular supervision and monitoring from
healthcare workers (Fleming et al., 2020). However, with increasingly diverse apps that are made
available and the high workload faced by many healthcare workers, the question of how they can
keep abreast with all of these developments to better support their patients has become an issue.
In addition, some applications may not have undergone rigorous research evaluations to
ascertain their safety before deployment for general use, raising issues on patient safety (Agboola
et al., 2016).
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Furthermore, in the case of telemedicine, when patient care is delivered remotely, physicians or
other healthcare workers may not detect subtle cues that they could detect from an in-person
consultation. While digital health technology that powers telemedicine enables the health system
to reap benefits that result from time and economic efficiencies, these virtual encounters could
potentially undermine patient safety if safeguarding mechanisms are inadequate (Agboola et al.,
2016). There is a fine line between patient empowerment and unregulated harm that these smart
apps can do to patients, and health authorities and health implementers will need to keep this
issue in check (Fleming et al., 2020).
An additional technical issue to ensuring patient safety is software quality. For instance, the
longevity and transparency of the software that powers an app has been raised as a concern that
is associated with patient safety. There is a risk to product safety that translates directly into
patient safety when the software lacks maintenance and updates, which will predispose it to
implementation flaws such as incorrect insulin-dosing recommendations by the manufacturers.
Furthermore, when a manufacturer ceases operations, there is uncertainty as to what will happen
to the technical support that was previously rendered to patients (Gordon & Stern, 2019).
Cybersecurity
A third governance challenge to the implementation of digital health technologies for public
health improvement is cybersecurity. As the functions of digital health technologies are
essentially configured by networking and software capabilities, this makes it vulnerable to
cybersecurity risks. For instance, there have been reports that hackers were able to remotely
control medical devices such as pacemakers and data from insulin pumps and modify their
functions remotely (Fleming et al., 2020; Gordon & Stern, 2019). These cyber-attacks can
potentially be life-threatening to patients and disrupt healthcare delivery.
One of the biggest motivating factors to such illicit means of obtaining health information via
attacking digital health information systems is the profit that comes along with the extraction of
these data. It was reported that the black-market value of digital health information is at least
10–20 times more than the value of data collected by credit card providers (Chernyshev et al.,
2018). Extortion or demands are not always targeted at the individuals whose information were
violated, but more at the health providers or authorities responsible for safeguarding their data
(Chernyshev et al., 2018). The accelerating growth of smartphone use is fueling the intensity of
cybersecurity attacks as well. The widespread “Android installer hijacking” that was publicly
disclosed in March 2015 was estimated to impact approximately 50% of all Android users at that
time. Attackers essentially replaced the Android app downloaded from third-party app stores
with malware to gain access to the device and obtain sensitive data, including usernames and
passwords, without users’ knowledge (Filkins et al., 2016).
In general, three major forms of cyber-attacks in the digital health space have been observed. The
first is ransomware attack. One of the most famous examples of this is the WannaCry ransomware
attack that happened in the United Kingdom in 2017, which paralyzed the health system for
almost a week. The WannaCry cyberattacks, which resulted in the shutdown of several hospitals
under the National Health Service and cancellation of about 600 surgeries and more than 19,000
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appointments (Alami et al., 2019), exposed the fundamental lack of sustained investment in the
healthcare industry to boost cybersecurity measures (Acronis, 2021). An impact analysis of this
cyberattack reported a significant decrease in the number of attendees and admissions among the
affected hospitals, which translated into £5.9 million lost in hospital activities (Ghafur et al.,
2019). Such attacks are detrimental to a country’s health system and incur both direct costs in
terms of revenue lost (e.g., ransom payment to the pirates/attackers and reparation payments to
the affected patients, loss of income due to its inability to run health services during the period
when the entire health information system was compromised) and indirect costs in terms of
tarnished reputation among the public (Alami et al., 2019). The second form of cyber-attack is
phishing. This attack is usually launched by sending malicious links or attachments to users via
emails and tricking them into opening those attachments (Acronis, 2021). The third form of
cyber-attack is privilege abuse, which emerges when an individual gains unauthorized access,
raises permission to gain access rights, or uses legitimate permissions to access data or records
either for personal gain or for malicious activities (Fimin, 2018). This is a tricky issue to govern as
the demarcation on the right to access the health information system is often unclear. While
some electronic medical record systems adhere to role-based access control policies to govern
against privilege abuse, other systems may not share the same degree of granularity.
Furthermore, in emergency situations that warrant open access to electronic medical records by
different levels of health providers or health workers, a restrictive role-based access control
policy may not be practical (Chernyshev et al., 2018).
Algorithmic Bias
Algorithmic bias has been raised as a key concern in the last decade following the proliferation of
artificial intelligence and machine learning tools in the digital health ecosystem. Concerns have
been raised on the dissemination of individual health data that can be used to calculate predictive
health scores in the United States (Humphreys, 2020). For instance, the Affordable Care Act
health risk score, which creates a relative measure of predicted health care costs for an enrollee,
has been used as a proxy to suggest how sick a person is; likewise, the brand name medicine
propensity score can be used as a proxy to predict how likely it is that one will choose brand-
name medications over generic medications (Humphreys, 2020). These data can be traded by data
brokers for commercial clients such as pharmaceuticals and insurers, who could use this
information to feed the algorithms in artificial intelligence systems and conduct risk profiling or
predictions that could potentially make biased decisions that are unfavorable to certain
subpopulations with disadvantaged backgrounds. Besides health risk profiling, racial profiling by
automated systems have also been raised. Studies have documented how machine learning and
algorithms behind digital tools or internet search engines perpetuate racial biases and
discriminations rather than eliminate them. This phenomenon, coined as “New Jim Code,” refers
to the embedded, invisible, and injurious biases behind decision making in automated systems
that are fed by biased datasets to begin with (Grande et al., 2020; Wilks, 2020).
A seminal study examining racial bias in the commercial prediction algorithm used to identify
patients with complex health needs with the intention to facilitate more targeted healthcare
programs for those who needed them most had revealed that when algorithmic risk score is
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conditional on cost, Black patients generated lower costs than White patients, but when the
algorithmic risk score is conditional on health risk proxied by the number of comorbidities, at any
given score a Black patient would present with more comorbidities than a White patient. The
results suggest the occurrence of racial algorithmic bias, which could inadvertently result in
health systems underserving Black patients when health needs are correlated with health costs
without accounting for the mechanisms of health inequality that are inherent in the population
(Obermeyer et al., 2019). Besides, another study also warned against the use of digital technology
such as facial recognition software and predictive policing without consideration of the inherent
demographic biases that have been inadvertently built into the system, especially in COVID-19
apps used for surveillance and contact tracing. Racialized groups and vulnerable subpopulations
tend to be subjected to higher levels of scrutiny and suffer greater negative repercussions from
racial profiling and disproportionate policing as compared to the general population. Without
addressing these issues, digital health tools that operate based on big data analytics may
aggravate the marginalization and stigma of the already vulnerable populations (Hendl et al.,
2020).
Liability
While the issue of liability has been discussed in other autonomous systems such as autonomous
vehicles (Taeihagh & Lim, 2018) and robotics for aged care (Tan et al., 2021), this issue has not
received as much attention in digital health technology. In the discussion on liability, the
question often revolves around which party should hold the ultimate responsibility in the event of
data breaches, or when any harms or injuries to the users are inadvertently caused by a
technology during its use. While logic may point to the device manufacturer as the party
responsible for faulty product in hardware medical devices, liability issue in software-enabled
medical devices may not be as clear cut. This is due to the fact the software embedded in the
digital health device may contain off-the-shelf components that are not created by the device’s
manufacturer and the software problems that surface at a later time by these off-the-shelf
distributors may impact the entire pool of existing device users (Gordon & Stern, 2019). A clear
liability regime that prescribes channels of redress or clear grievance mechanisms for all parties
involved in the development, manufacturing, distribution, and implementation of digital health
devices is thus necessary moving forward.
Autonomy
One of the most salient issues related to autonomy is a question related to access: Can patients
have access to their health data for health monitoring purposes, and what is the extent to which
their health data access—whether in summary/aggregate form or in more granular detail—ought
to be granted? From patients’ perspectives, having the autonomy to access their health data on
the digital health devices that they are using is useful for more frequent and effective self-
monitoring. For instance, a heart patient with a cardiac device installed in his/her body may want
to have access to his or her personal health data such as measurements of physiologic
parameters, heart rate variability, or arrhythmia burden on a daily basis instead of a longer
duration in order to inform their medication titration. Likewise, patients with frequent but
Page 13 of 22
nonspecific palpitations may want to correlate their experiences with the digital health device
data more frequently than they would want to consult their clinicians. Even though these data are
important to enable more effective self-management, the ability to enable more granular access
of digital device data is often conditioned on the ability of the clinicians to review these data
regularly (Cohen et al., 2020). The tension between autonomy of data access and ensuring patient
safety may imply that there is no immediate or fast resolution to this issue.
Social Justice
Social justice is another fundamental ethical challenge that needs to be considered during the
implementation of population-level digital health interventions. Specifically, it is of paramount
importance to consider three issues pertaining to social justice—availability of digital health
services or infrastructures that support them, affordability of these interventions, and access to
technology (Brall et al., 2019). For some traditionally underserved communities and vulnerable
populations such as the elderly, low-income population, and homeless people, fairness and
equity will need to be addressed long before rolling out digital health solutions to a wider
population. Other sociocultural barriers such as values, norms, health beliefs, and digital literacy
that could decrease engagement with technology among certain populations should also be
considered (Brall et al., 2019; Crawford & Serhal, 2020). Since November 2019, the issue of
fairness and justice in the use of COVID-19 surveillance apps designed to control infection rates
has also been raised. Research has shown that in some countries, these apps have subjected
racialized groups to disproportionate policing and profiling, raising concerns on digital health
technology exacerbating the marginalization of these subpopulations (Hendl et al., 2020).
The above sociocultural determinants and structural issues should be constantly addressed when
implementing digital health solutions at the population level. This is so that every well-intended
digital health solution will not risk widening health inequality in society, but instead fulfilling its
promise to be a social leveler.
Conclusion
Herein we presented a balanced discussion on the benefits of digital health solutions to public
health and the potential flaws that could ensue without clear regulatory provisions. While digital
health solutions raise hopes and promises for a better world with improved health equity and
population health outcomes, there are legitimate governance issues and ethical challenges that
need to be addressed through ongoing engagement from various actors in the digital health
ecosystem.
To ensure that the world can reap tangible benefits and positive impacts from large-scale
deployment of various digital health solutions, countries need to first devise national digital
health strategies to create a blueprint or master plan for digital health. For instance, the World
Health Organization unveiled a global digital health strategy in 2020 to chart the blueprint for
digital health from 2021 to 2024 (World Health Organization, 2021). This will be an entry point for
countries inclining to draw lessons for digital health planning.
Page 14 of 22
In addition, digital health equity will need to be prioritized by governments and policymakers to
expand digital outreach to the vulnerable populations. This can be addressed by incorporating
“ethics by design” prior to the implementation of digital health solutions to ensure that issues
related to availability of services, and users’ affordability and accessibility toward the technology,
are being considered (Brall et al., 2019). Beyond this, it is important for governments to collect
digital health equity data to understand facilitators and barriers to digital health solutions among
different segments of the population (Crawford & Serhal, 2020).
For low- and middle-income countries, having a mature digital health infrastructure remains a
work in progress and hence governments from these countries will have to build capacity to
strengthen these infrastructures to enable large-scale implementations of digital health
technologies. This can be achieved by promoting regional learning networks to promote country-
to-country or city-to-city knowledge and technology transfer among different countries (Tan et
al., 2021), as well as setting up regulatory sandboxes and testbeds to balance the need for
technological innovation and regulatory provisions to minimize the risks and unintended
consequences arising from the deployment of technologies (Tan & Taeihagh, 2021).
It is no longer realistic for any country to resist the adoption of digital health technology with the
arrival of the artificial intelligence era. With thoughtful design and careful implementation,
countries will be more equipped to ward off the precarious aspects of digital health solutions and
maximize their potential to improve social well-being and population health outcomes.
Further Reading
Budd, J., Miller, B. S., Manning, E. M., Lampos, V., Zhuang, M., Edelstein, M., Rees, G., Emery, V. C., Stevens, M. M.,
Keegan, N., Short, M. J., Pillay D., Manley, E., Cox, I. J., Heymann, D., Johnson, A. M., & McKendry, R. A. (2020). Digital
technologies in the public-health response to COVID-19 <https://doi.org/10.1038/s41591-020-1011-4>. Nature Medicine,
26, 1183–1192.
Gómez-Ramírez, O., Iyamu, I., Ablona, A., Watt, S., Xu, A. X. T., Chang, H. J., & Gilbert, M. (2021). On the imperative of
thinking through the ethical, health equity, and social justice possibilities and limits of digital technologies in public
health <https://doi.org/10.17269/s41997-021-00487-7>. Canadian Journal of Public Health, 112(3), 412–416.
Grande, D., Marti, X. L., Feuerstein-Simon, R., Merchant, R. M., Asch, D. A., Lewson, A., & Cannuscio, C. C. (2020). Health
policy and privacy challenges associated with digital technology <https://doi.org/10.1001/jamanetworkopen.
2020.8285>. JAMA Network Open, 3(7), e208285.
Khoury, M. J., Bowen, M. S., Clyne, M., Dotson, W. D., Gwinn, M. L., Green, R. F., Kolor, K., Rodriguez, J. L., Wulf, A., & Yu,
W. (2018). From public health genomics to precision public health: A 20-year journey <https://doi.org/10.1038/gim.
2017.211>. Genetics in Medicine, 20(6), 574–582.
Merlin Chowkwanyun, M., Bayer, R., & Galea, S. (2018). “Precision” public health-between novelty and hype <https://
doi.org/10.1056/NEJMp1806634>. The New England Journal of Medicine, 2018(379), 1398–1400.
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Tan, S. Y., Taeihagh, A., & Tripathi, A. (2021). Tensions and antagonistic interactions of risks and ethics of using
robotics and autonomous systems in long-term care <https://doi.org/10.1016/j.techfore.2021.120686>. Technological
Forecasting and Social Change, 167, 120686.
Taylor-Robinson, D., & Kee, F. (2019). Precision public health-the emperor’s new clothes <https://doi.org/10.1093/ije/
dyy184>. International Journal of Epidemiology, 48(1), 1–6.
Willems, S. H., Rao, J., Bhambere, S., Patel, D., Biggins, Y., & Guite, J. W. (2021). Digital solutions to alleviate the burden
on health systems during a public health care crisis: COVID-19 as an opportunity. JMIR mHealth and uHealth, 9(6),
e25021.
Yates, S. J., & Rice, R. E. (2020). The Oxford handbook of digital technology and society. Oxford University Press.
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Digital Solutions to Public Health Issues

Digital Solutions to Public Health Issues

Subjects: Biostatistics and Data

Some Examples of Digital Solutions to Public Health Issues

Improving Access to an Increased Range of Health Services and the Potential of

Maximizing Population-Wide Health Impacts Through Behavioral Modifications

Controlling and Managing Public Health Emergencies

Conceptual Framework: The Three Major Applications of Digital Solutions

Figure 1. Three major roles of digital solutions to public health issues.

Monitoring: Effective Disease Screening and Pandemic Control

the chain of human-to-human transmission. As most epidemic/pandemic-causing infectious

Decision Support: Promoting Behavior Modifications and Optimizing Resource

Education: Improving Health Knowledge and Awareness

Governance Issues and Ethical Challenges

Data Privacy and Erosion of Trust

Fimin, M. (2018). Privilege abuse attacks: 4 common scenarios <https://www.darkreading.com/endpoint/privilege-

Ledger, D. (2014). Inside wearables—Part 2. Endeavour Partners.

Marsch, L. A. (2021). Digital health data-driven approaches to understand human behavior.

following the concepts of predictive, preventive and personalized medicine <https://doi.org/10.1007/

Health Information Systems and Migrant Health in Europe

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