Omnichannel Communication to Boost Patient Engagement and Behavioural Change with Digital Health Interventions

Digital health interventions (DHIs) are being increasingly incorporated into healthcare workflows to improve the efficiency of patient care. In turn, sustained patient engagement with DHIs can maximise their benefits towards healthcare outcomes. In this viewpoint, we outline a framework for dynamic patient engagement using various communication channels and the potential use of omnichannel engagement (OCE) to integrate these channels. We conceptualise a novel patient care journey where multiple online and offline communication channels are integrated through a ‘digital twin’. The principles of implementing OCE for DHI and digital twins are also broadly covered. OCE in DHI implies a flexibility for personalisation which can enhance and sustain patient engagement with DHI, and ultimately patient quality of care and outcomes. We believe the novel concept of OCE in healthcare can be greatly beneficial to the patients and the system once it is successfully realised to its full potential.


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Yes, but please make my accepted manuscript PDF available only to logged-in users; I understand that the title and abstract will remain v Yes, but only make the title and abstract visible (see Important note, above).I understand that if I later pay to participate in <a href="http  OCE in DHI implies a flexibility for personalisation which can enhance and sustain patient engagement with DHI, and ultimately patient quality of care and outcomes.We believe the novel concept of OCE in healthcare can be greatly beneficial to the patients and the system once it is successfully realised to its full potential.The current pandemic has accelerated the adoption of digital health services and telemedicine on a global scale, with large programs already deployed in clinical practice.[3,4] With rapid digitalisation of healthcare coupled with recent efforts to reimburse DHIs (e.g., DiGA in Germany, the mHealthBELGIUM platform in Belgium and NHS Scotland) and the emergence of new digital interaction modalities, e.g.Metaverse [5] as potential interfaces for DHI in the future, guidance on how to best improve an individual's health with DHI is direly needed, including effective engagement strategies.

KEYWORDS:
Here we set out to identify, in broad strokes, how DHIs could be potentially integrated into future healthcare.We focus on patient engagement as the most crucial component to effectively change the behaviour of the patient via DHIs.[6] Through patient engagement it is possible to reshape behavioural intentions, motivations and attitudes, as well as provide direct and continuous feedback on the effect of the changed behaviour, which can further reinforce and sustain appropriate change.
[7,8] Despite its significant role for digital health tools efficiency, patient engagement in the context of "last-foot delivery" of DHI has not yet been explored to its full potential.

Communication channels for engagement in DHI and behavioural change
Engagement during an intervention is a dynamic process which can begin passively (e.g.hearing about the intervention through peers or doctors, advertisement etc.), followed by more active interactions during initial and continued usage.[9] According to an integrated conceptual framework for health marketing communications, [8] the communication potential and goals vary through different stages of patient interaction with DHI (Figure 1).Given the variety and adaptability of communication channels, [10] deploying the right communication channels and their dynamic adaptation throughout the intervention period can be leveraged as an effective means to build and sustain patient engagement.Firstly, patients need to form the motivation for using the DHI by means of prior information and involvement.[8] For this it is crucial to raise awareness about the health issue and DHI through physical channels, such as healthcare providers and traditional mass media, and virtual channels, such as social media.As awareness for the DHI is increased for each patient, communication channels can evolve to become more personalised and engage patients more actively.During this stage, promoting motivation to change, forming behavioural intentions and new positive attitudes are essential.[8] Increasing autonomous motivation has been shown to lead to positive health behavioural changes, [11] and simultaneous use of multiple communication channels has the potential to employ a variety of motivation and behaviour change techniques.[12] Eventually, as patients progress through the DHI process with high motivation and engagement, the goals of communication channels should shift towards initiating and maintaining changed behaviour through less effortful thinking.At this stage, continued cue to action through moderate reminders and the use of peripheral cues, such as recommendations from doctors and discussion with other patients, can be beneficial.[8] Different communication channels can serve different roles and affect patient adoption of DHI at different stages of their treatment (Table 1).As such, patient engagement shall remain dynamic as informed by the stage of their journey together with the information collected through the longitudinal intervention monitoring, in e.g., a feedback-loop or adaptive mechanism.
Table 1.Potential applications and patient adoption considerations of selected communication channels.

Pre-intervention Intervention and post intervention
In-person visit consultation with a physician, a rehabilitation session in a centre, monitoring and drug titration with specialized nurses, etc.

Email email consultations, communication of test results, ereferral, etc.
Asynchronous communication, both convenient and nondisruptive in the day-to-day lives of patients.

Videoconsultation tele-consultation, e-prescription, e-referral, etc.
Synchronous communication, initial adoption can be affected by ease of use and perceived usefulness. 45  Active communication channel, can be used to replace in-person visits for higher engagement but patient satisfaction is essential for continued usage. 46Common issues include problems with internet connectivity and accessibility. 47

Mobile applications
Wellness apps, screening and monitoring solutions, or therapeutic interventions (Digital Therapeutics), with e.g., VRbased therapy, personalized nudges and/ or RWE collection.
Initial adoption can be affected by ease of usage and user interface.
Involvement of healthcare providers and public health authorities can benefit adoption. 48  Ease of use in long term, enables disease monitoring and symptom tracking.Usage can be sustained through generating electronic satisfaction. 49

Digital social environment
Social media and metaverse that can be used for educating, supporting and influencing behaviour change, as well as individualized lifestyle improvement and e.g.dietary recommendations.

Adoption might be affected by digital divide and privacy concerns
Enables patients' engagement with the ability to share, comment on and react but also social norms intervention, especially for the young adults. 50

Online platforms
Online learning/ educational platforms such as internet-based diabetes management platform or digital PROM and ePRO platforms.
Adoption determinants include reliability of provider, level of awareness towards e-health platform and accessibility. 51  Enables selfmanagement.Continued engagement relies on confirmation of user's initial expectations and perceived usefulness. 52

SMS-based communication, chatbot, virtual health assistant, messaging apps for just-in-time interventions, triaging, etc.
Familiar platform and increased ease of usage to encourage adoption.Limited with regards to nature and amount of information shared.Narrative persuasion through first-person point of view can impact persuasion of health messages. 53  Enables reminders for chronic disease management.Limited in terms of clinical data sharing --quality of responsiveness and variability can help improve conversation quality. 54

Safe messaging apps
Direct messaging to healthcare providers, appointment booking, patient reminders, data sharing between healthcare providers, patient data storage Adoption is influenced by convenience and the integration of safe messaging apps to electronic health record systems. 31  Continued usage relies on patient's preference for enhanced security features and ease of use.

Voice-based assistant
Smart home and mobile-based digital assistant that enable proactive reminders, remote care access, and/or the ability to capture patients' responses to e.g., a questionnaire.AI-powered voice biomarkers could also be used to screen for and diagnose a wide range of diseases as well as triaging The relative simplicity lowers traditional technological barriers and provides the benefits of hands-free and eyes-free engagement mode.The disadvantages are that some patients may have difficulty in formulating a structured sentence for a command, as well as may have privacy concerns associated with having a voice assistant "always-on". 56  Potential for passive symptom tracking and just-in-time interventions.

GPS tracking devices, Bluetooth beacon technology, body vitals sensors, etc.
Initial adoption can be affected by novelty of wearable technology -e.g., design aesthetic is a prominent factor when influencing behavioural intention. 57  Enables passive symptom tracking and generates long-term data for feedback and analysis.Continued perceived usefulness and positive attitude need to be maintained. 57  AI, Artificial Intelligence; GPS, global positioning system; PROM, patient-reported outcome measure; RWE, real-world evidence; SMS, short message service; VR, virtual reality For optimal personalisation and seamless integration, the DHI needs to adapt to the user communication preferences, which vary with demographics, psychographics and the specific health condition.[27,28] Broadly, young adults prefer solutions that blend in -are accessible through existing hardware and software, have a familiar syntax (e.g.use of emoticons) and are aligned with the existing habits.[29] Older adults, often with limited IT skills, also prefer familiar and/or easy-touse communication channels for DHI.[27,28] Despite the stated importance of a seamless and personalised experience in healthcare across physical and virtual channels, [30] many of the current DHIs are unable to integrate seamlessly with each other and the rest of the healthcare system to personalise and improve engagement.The lack of integration of DHIs in the patient journey can exacerbate the existing healthcare fragmentation, particularly evident in the gaps in continuity of care between the hospital and outpatient treatments.The effect of this discontinuity in user experience, among others, shows in the attrition rates with digital health apps.In one of many examples, the usage analysis of 57 mental health apps showed that the percentage of users that opened the app dropped from 69.4% to 3.9% within the first 15 days [31] potentially rendering them ineffective.Rapid disengagement is a particularly detrimental issue for DHI's that target chronic diseases, where continuity of care is crucial.

Omnichannel engagement for DHI-led behavioural change
Encouraged by its success in retail, [32] we identified omnichannel engagement (OCE) as a highly promising and untapped approach for DHI patient engagement.OCE attempts to integrate and interconnect multiple communication channels in a synchronised operating model which leverages data and digital tools to deliver a seamless, consistent, and personalised experience for the user. [33] The key features of OCE are:  Integrated and interconnected communication using multiple available channels  Synchronised / coordinated activity  Personalised and consistent experience for the user

 Continuous improvement via data and digital tools
We envision a patient journey of the future where DHIs are a crucial part of a stand-alone or auxiliary treatment and behavioural change, and leverage OCE for the greatest possible impact.In our vision, DHIs are distributed into several services (dedicated disease service, tracking service), which are integrated with various communication channels as well as wearables / sensors and the web environment of the patient.A "digital twin" of the patient forms the necessary backbone, centrally collecting and integrating all relevant data -medical data, connections, preferences, and insights that allow to design and monitor an actionable behavioural intervention.This digital twin may not need to encompass all available data but merely has access to multiple sources such as the personal health record (PHR) in order to gain sufficient insights in order to be actionable.For example, to gauge the phenotypic response and recommend an optimal pharmacological dosage with sufficient safety and accuracy, only 3-6 data pairs may be necessary.[34,35] Importantly, it will be required to find the right balance of complexity and size of the data model versus the quality and rapid generation of actionable insights.OCE serves the purpose of linking the patient to a network of health services through various integrated communication channels revolving around the patient's health seeking experience.In already existing examples, instant messaging, be it stand-alone (e.g.WhatsApp), or linked to social media (e.g.Facebook Messenger) can be used for triaging in-person and online consultations.[36] Wearables enable long-term symptom management, and emails and teleconsultations provide a seamless and convenient method for follow-ups and communication of clinical data.These services can be combined with the aligned nudges for lifestyle and nutritional choices, e.g., specific food suggestions when shopping online.OCE also creates opportunities for obtaining additional insights.An analysis of the interconnection between communication channels may allow for analysis of the network of communication and support, which can be a powerful ally for behavioural change.In one example, obesity is known to spread through social ties [37] through a diffusion of unhealthy behaviours, including physical inactivity.[38] Accordingly, social connections become informal channels of information with real impact on health decisions, for self and others, e.g. in parenting.[30] Indeed, rapid diffusion of information has been demonstrated within social networks.[40] Such insights could lead to broader understanding of one's behaviour motivators and their environment to launch a precise digital health intervention and form beneficial habits.

Supporting the patient journey with DHI and OCE
Here we outline how DHI with OCE may work as an auxiliary healthcare tool.At the beginning of the patient journey (Figure 2), individuals at risk of a disease receive broadly targeted medical information through passive communication, with which they can decide to follow-up.Interested individuals are supported by an automatic screening procedure in deciding whether contact with a healthcare professional is necessary.If this is the case, an initial contact is a telemedicine consultation.This allows for a low-cost and rapid way to establish an initial differential diagnosis, diagnostic workup, and treatment plan.The patient can be instructed on the necessary data to be collected, e.g., symptom diary, wearables or other tracking platform, to improve the positive predictive value of diagnostic procedures.Once sufficient data have been collected, an in-person visit with a healthcare practitioner follows, during which more clinical data is gathered and the treatment plan is adapted.Ideally, necessary additional wearables and the correct instruction for the new or already used ones are provided at this appointment, together with recommendation/prescription of an appropriate DHI.Following this are two parallel tracks: while the DHI is applied to the patient to change behaviour and monitor progress / treatment compliance; the patient also follows-up on visits to diagnostic services (e.g., MRI), therapeutic services (e.g.physical therapy, nutritional specialist), a visit to the doctor's office and further visits with the healthcare practitioner as necessary.Ideally, thanks to the adaptive engagement for DHI via OCE, the patient adherence to both on-and off-line components is high, leading to a rapid and sustained shift in behaviour and ultimately better outcomes while reducing the most resource intense engagements, i.e., face-to-face visits.Once treatment is completed, DHI continues to support the habituation of behaviour and thus provides secondary prevention.In patients with chronic diseases, telemedical visits continue as necessary for treatment plan adaptation while DHI provides a much closer view of disease state and offers an asynchronous way for the healthcare practitioner to stay up to date on the patient status.
To allow the flexibility necessary for this approach, it is crucial that healthcare professionals are agnostic to the effective engagement channel and that their primary systems used to document clinical data support the integration with the patient's digital twin.Moreover, healthcare professionals may be required to assess individuals who will most likely need assistance with the setup and use of DHIs.[41] While patients are increasingly open to incorporating technology as part of their care delivery, [42] continual efforts through personalisation, understanding the resources and capabilities of targeted patient populations should be made to promote greater technology access and literacy.
As we continue to broaden healthcare professionals' responsibilities, new skills may become necessary, and a new role of the digital health specialist may emerge as a primary healthcare provider of the future.

Challenges to implementing DHI with OCE
The presented approach, incorporating a digital twin of the patient as well as OCE, needs to align with the collectively accepted principles and values, such as regulatory compliance, as well as "privacy, equity, fairness, patient safety, and patient autonomy over health-care decisions".[43] While DHI may aim to pragmatically increase patient autonomy, the data they use and generate can be seen as a commercial asset, giving rise to risks such as the breach of data security or privacy as well as data governance issues.Adding to this complexity, DHI operating in multiple countries will need to comply with local, national, regional and international standards.
How can data privacy be ensured while 1) using available communication channels and 2) tracking patient preferences and managing the intervention via digital twin?
The General Data Protection Regulation (GDPR), one of the most stringent and comprehensive frameworks and regarded as the "toughest privacy and security law in the world" [44] may be a good starting point.However, due to the allowance for further specifications in EU member states, care still must be taken to adapt to the specific country where a DHI is deployed.Typical caveats include the physical location of data, the way in which patient consent is gathered and the necessity for consent before sharing data with specific third parties, such as insurers.A particular example in the context of DHI with OCE is integration with WhatsApp, [23] a popular messaging application in clinical settings, which fails to comply with GDPR regulations as messages are stored on servers outside the EU.In fact, a vast majority of health apps fall outside the remit of effective regulations in most nations.[45] Though Secure Messaging Apps (SMA) are being developed and marketed with increased data privacy [46][47][48][49][50], it is yet unclear how stringently they comply with GDPR, and how they can be potentially adapted for future integration with DHI while also ensuring sustained compliance.
Patients should be empowered with increased information and awareness of their own healthcare journey as authorities establish the balance between data protection and data exchange, and new governance models arise.Where appropriate, they may also be given the opportunity to participate actively in their own health decisions and treatment by fully utilising their health data rights.Among others, an open question remains on the mechanisms to guarantee patient-controlled access to their own data, and broadly speaking to the digital twin.The digital twin represents an actionable collection of information designed specifically to be able to "connect the dots" and both predict, monitor, and influence a patient's behaviour -it easily represents the riskiest component of our vision.Conceptually, new decentralised technologies, like blockchain, may support the control over access and secure information flow in the digital twin [51,52], however, those are not yet broadly adopted and beyond technical challenges a regulatory shift and user education is required to minimise the risk of the digital twin being used as a mean to influence the autonomy of the healthcare decisions.Some regulatory bodies have issued laws attempting to realise publicly controlled digital twin-like patient profiles (e.g., the National Electronic Patient Record (ePA) in Germany, the National Electronic Health Record (NEHR) in Singapore, or the Electronic Patient Dossier (EPD) in Switzerland).However, realisation efforts haven't yet shown results.The key benefit of such a data exchange system is to overcome challenges encountered with traditional or historical systems interoperability approaches, and to enable data exchange between healthcare professionals.As illustrated in Figure 2, we are however still some distance away from a comprehensive patientspecific digital twin that combines all clinical and non-clinical data.

CONCLUSIONS
While we have outlined the principles and challenges of DHI combined with patient engagement through OCE in this viewpoint, it is the evidence stemming from trials and real-world data that will verify the true value of such an approach.One strategy to rapidly pilot potential OCE for DHI could be the combination of a wellness/lifestyle intervention with a healthcare intervention.This could provide initial evidence for increased patient engagement while testing the concept of continuous improvement with data generated through the engagement.Further integration, e.g., with a PHR could then be added in a second phase.However, we do not see this as a bypass for adhering to the appropriate healthcare and data privacy regulations.Recently, there have been worrisome reports of the breaches of data privacy and data security by wellness applications.[53][54][55] In addition to data breaches, other concerns include the aggregation of multisource data and generating digital twins without appropriate access control for the individual represented by the digital twin.
The Sustainable Development Goals Recommendation (SDGs) state that digital health is a means of promoting equitable, affordable and universal access to health for all, including the special needs of groups that are vulnerable in the context of digital health.[56] Yet, DHIs need proof of effectiveness, accessibility, feasibility, sustainable resource use and the observation of equity and rights to truly fulfil that role.[2] The extent of success of DHIs in changing health outcomes depends on the level of patient engagement during the intervention and subsequent sustained change of the intended health behaviour.[57] Capitalising on the adaptability of OCE, there is potential for personalising the user experience to each patient and the flexibility to adapt to different regions contingent on the needs and regulations of each country.Unanswered questions remain with regards to the emergence of new communication channels and behaviours in a digital space as well as adoptions of healthcare models and roles.In addition, the type of investments and balance of commercial vs healthcare interests or the integration of particular channels should also be considered.However, we believe that DHIs focused on patient engagement through a dynamic, adaptable OCE approach and building on a well-formed, compliant digital twin, have the potential to greatly improve future health while disrupting unsustainable healthcare systems.

ABSTRACT
Digital health interventions (DHIs) are being increasingly incorporated into healthcare workflows to improve the efficiency of patient care.In turn, sustained patient engagement with DHIs can maximise their benefits towards healthcare outcomes.In this viewpoint, we outline a framework for dynamic patient engagement using various communication channels and the potential use of omnichannel engagement (OCE) to integrate these channels.We conceptualise a novel patient care journey where multiple online and offline communication channels are integrated through a 'digital twin'.The principles of implementing OCE for DHI and digital twins are also broadly covered.
Digital Health Intervention; Omnichannel Engagement; Behavioural Change; Communication Channels; Personalized Engagement; INTRODUCTION Digital health interventions (DHIs) -digital tools that help modify individual's health behaviour through direct interaction -are part of a novel field of digital health, often referred to as the next frontier in healthcare.Today, a wide range of digital health technologies across the spectrum of mobile health, health information technology, wearable devices, telehealth and personalised medicine solutions [1] are being explored in a variety of settings.These approaches can potentially improve the quality, accessibility, and affordability of healthcare worldwide.[2] Moreover, thanks to their typically privileged access to the individual by virtue of their proximity and omnipresence, e.g.via smartphone, DHIs successfully implemented in a clinical practice can achieve what healthcare providers dream of -driving patients' health behavioural change in response to the real-time tracking of the intervention progress.

[ 8 ]Figure 1 .
Figure 1.Communication framework for digital health intervention (DHI).The potential role of communication towards behavioural change pre-and during DHI as guided by the framework proposed by Manika & Gregory-Smith.[8]

Figure 2 .
Figure 2. Patient journey with digital health intervention through omnichannel engagement.The section above the arrow presents selected communication channels with direct interface to the patient, where patient is the main data steward.The section below the arrow provides selected communication channels where the patient interacts with Healthcare Professionals (HCPs), and they are the main data stewards.VR, Virtual Reality; AR, Augmented Reality, ePROs, electronic Patient Reported Outcomes; PREMs, Patient Reported Experience Measures.