In Defense of Digital Health! (part 1)

The intricacy of technology adoption is a well studied yet confusing process. Change in healthcare specifically, can be brutal. New empires are created while others fall. Yet others adapt.

This article in JAMA — “Digital Health — The Need to Assess Benefits, Risks, and Value,” written by intelligent and well intentioned researchers, was published on December 20, 2020 and describes a “…buyer beware” approach to digital health.

Does it have good points? Yes, especially in the area of digital health cybersecurity. However, there’s little use in taking an overly cautious, alarmist view of digital health using standards that we don’t apply to other equally important technologies in daily use. To avoid brain injury from power point (there should be an ICD10 code for that) I wrote a parody article using another technology we already use: email.

Digital mail or “email” [ee-mail bruh] is a broad spectrum of communication technologies that include websites, smartphone apps in people’s homes, workplaces, and communities. Email offers novel ways to capture and convey human thoughts, gifs, memes, attachments, useless ads, and links to NSFW youtube videos from one individual to another and across populations. These technologies complement the episodic “snail” mail from individuals captured by current, traditional courier based approaches. Email has the potential to revolutionize communications, bring low cost and immediate interaction between people in different places, and improve commerce but the current state of technology development and deployment, as it threatens the current statues quo, requires a “buyer beware” cautionary note.

Digital Email Modalities

Electronic mail systems and mobile mail apps contribute to an increasing flow of message data. To provide meaningful mail applications, these data require standardized high-quality formats, seamless communications, and integration across technology systems. Many digital email devices seek to replace or improve traditional mail devices such as mail trucks, human couriers, and envelopes. For example, email status can be detected by computer code that measure notification and email icon badge count. But it is important for mail recipients to understand that even though these devices have no tangible markers of fidelity including envelope closure security, red twine,post mark, stamp, or overpriced post office tape there may be a false-positive sense of security that may incur additional expenses requiring trips to the post office to your local post office.

Important Email Considerations

It is important to understand that traditional mail devices can be approved or cleared by the US Postal Service. Approved devices have been studied postally and determined to provide benefits that outweigh any corresponding risks (e.g. door opening in high winds, student driver impact resistance). Cleared devices need only to demonstrate “substantial equivalence” to an already approved mailbox and are usually reserved for individuals going for a pretentious look.

Clearly, Email tools should undergo the same rigorous testing that other postal devices, and courier systems undergo before widespread adoption. Are email boxes weather proof and secured firmly into the ground? Do they come with customer service? Do they clearly post times of operation? How can one tell if the internet tubes are open and unclogged? How much does an email weigh and how much does it cost to send per ounce? Will consumers be confused by the fact that their physical “Inbox” and “Outbox” will be replaced by icons? These are all important questions to ask to your email provider.

Technologic innovation often comes with a new set of ethical considerations, challenges, and anxiety for institutions guarding the status quo. Policy issues for digital email will need to be addressed as adoption accelerates. Beyond the familiar potential risks, difficulty interpreting emoji, having to find the @ symbol, digital email tools carry an array of hidden risks. An increase in email has been shown to lead to repetitive use injuries, carpal tunnel syndrome, and fear of unable to send attachments over 10mb. More concerning is how these risks amplify geometrically for potential mental health problems such as anxiety and suspicion over use of the “Cc” and “Bcc” feature. Given that anxiety is the number one mental health problem in the United States with over 40 million people affected email poses a serious threat.1 These are not futuristic threats but are already here.


Understanding the full value of email is likely to be quite challenging. First, the variety of digital email tools is quickly expanding in ways that make blanket value discernment difficult. Some tools bring digital email scheduling, others bring novel capabilities that do more with a right click; both are valuable but difficult to quantify because of lack of comparators. We couldn’t possible imagine comparing regular email efficacy, speed, reach, cost with say, something like, traditional physical mail. Second, with respect to direct postal utility, few of these technologies are currently reimbursed, and the financial costs will likely be emailer’s responsibility for the foreseeable future. Because, as some case reports suggest, that email is providing new messaging opportunities for communication that would otherwise not be realized., ultimately require postal trials to demonstrate utility and justify their use. Common sense comparisons and assessment of value is not recommended.

Evidence Base

Currently, no major courier guidelines have incorporated digital email tools. Probably due to the fact that Few digital email technologies have been rigorously shown to be equivalent to standard, accepted courier standards. Postal trials are ongoing and there is a clear interest in determining the full potential of email. Thus, given the expense and unknown benefit-risk profiles of many email tools, they should, for the moment, be considered experimental. Who is going to pay for email services and how will the USPS be reimbursed for loss of stamp revenue and costs charged for bubble wrap?

Given the considerable commercial pressures to drive digital email adoption, the United States Postal Service may need to decide whether to recommend an email tool before evidence-based guidelines exist to guide adoption.

Digital email is nascent and is ushering in new data streams to augment envelope care and stamp decision-making. As these technologies become standardized and interoperable, and as evidence of envelope utility develops, mail management will become more efficient and effective. At the same time, potential risks must be addressed to reduce user vulnerabilities to attacks. Until then, digital email adoption will be a challenge to its widespread use.

Physician, Digital Health Entrepreneur, Troublemaker

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