Healio interview

Disclosures: Klonoff reports he is a consultant for EOFlow, Fractyl, Lifecare, Novo Nordisk, Roche Diagnostics, Samsung and Thirdwayv.
July 23, 2021
5 min read

Connectivity, digital tools becoming the ‘sixth vital sign’ in health care


Healio interview

Disclosures: Klonoff reports he is a consultant for EOFlow, Fractyl, Lifecare, Novo Nordisk, Roche Diagnostics, Samsung and Thirdwayv.
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Determining someone’s digital health connectivity may be just as important as measuring their blood pressure, pulse or body temperature.

In a commentary published in the Journal of Diabetes Science and Technology, David C. Klonoff, MD, medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California, and colleagues wrote that a patient’s ability to connect with digital health platforms should be considered the “sixth vital sign” for providers.

Klonoff is medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California.

Klonoff proposed a 10-question, yes-or-no patient survey of virtual care affordability, device accessibility, data privacy and security, with each affirmative answer indicating greater connectivity.

“The barriers to connectivity, in terms of economic and technical, are coming down rapidly,” Klonoff told Healio. “A big barrier, though, is a person’s own interest — they have to be motivated. Certain people who don’t want to use computers, don’t want to use smartphones, are missing out on access to information and treatment plans that would otherwise be available. It’s a combination of having the right hardware and software and reimbursement, but importantly, having the right motivation.”

Klonoff spoke with Healio about the digital connectivity questionnaire, benefits for patients, and how digital tools are transforming the health care industry.

Healio: Why did you describe digital connectivity as the sixth vital sign?

Klonoff: We traditionally think of vital signs as numbers or factors that contribute to an assessment of overall health. There are so many opportunities for improving health by using digital tools, both sensors and telehealth, that having access or partaking of opportunities to use digital health can make a big difference in outcomes for every medical condition. If there’s a lack of digital connectivity, then one misses out on opportunities and their opportunity for having good health is degraded. Digital connectivity is an important factor in overall health and can be considered, in a broad sense, as a vital sign. It’s not the same kind of vital sign one measures during a physical examination, but it has as much predictive value for a patient’s overall health.

Healio: How can digital tools improve health outcomes?

Klonoff: Digital health tools are generally some type of wearable sensor along with a wireless transmission to a smartphone, which accommodates data. The third element is a mobile application that takes the sensor information and transforms it into something useful, be it an analysis of the data or a recommended treatment. When people have access to information about their bodies and can combine it with information from databases, they can have access to information, to plans, to treatments that they would not normally have access to.

A tool that works hand in hand with digital health is telehealth. Telehealth allows people to communicate remotely with their health care professionals, either in real time or asynchronously.

To make the most of this connected health care world, you need to have a sensor and be willing to wear it, you have to have a smartphone, you have to be able to use software to some extent. You need to have some numeracy and some literacy skills. You need to have a communication portal with the health care system, which is some type of computer that can support video conferencing. Then there has to be an infrastructure in place. You have to have a doctor or teams of doctors who use these kinds of systems. They’re out there in every city in the United States. It helps if you have insurance coverage, but almost all of the insurance plans are now covering digital health tools and telehealth communication.

Healio: What is the purpose of the digital connectivity questionnaire?

Klonoff: Patients receive a digital connectivity score. This is a unique vital sign, we’re not talking about making a physical measurement, it’s more of your experiences and your capabilities. We decided to make it a composite score, which means there is no single element of connectivity that says you are or are not well connected, but it’s more of a combination of various accomplishments. The model for this was an Apgar score, which is a score of zero to 10 given to a newborn based on how the baby is functioning on different organ systems. We thought 10 was a good number to give us a broad perspective of how someone is doing, so we came up with 10 questions that overall give you your score for connectivity.

Healio: Do you think further changes are still to come with digital health?

Klonoff: We’re right in the middle of an extremely rapid evolution in health care. People have quickly adopted telehealth. Two years ago, it was considered weird, and now it’s considered mainstream. Today, most people have a smartphone and so they have access to sensor data, access to the internet and access to apps. They may not use them much — and a lot of them aren’t good — but people are using the good ones. Pretty soon, everybody has got to just assume they will get at least part of their health care through electronic means, whether it’s through the use of sensors with wireless transmission or through telehealth communication with their doctor. This old saying will be true: Digital health will be health.

I’m working on a project right now to analyze the effects of direct-to-consumer health care. At one point, it seemed like it was going to be a competition between direct-to-consumer health care and traditional health care delivering care through telehealth. It’s no contest now. Health care professionals will always be there when you have to see them in person, and hospitals will always be there. But when you don’t have to be seen in person, telehealth is not only going to dominate, but organizations that offer telehealth are going to dominate. Brick-and-mortar health care delivery systems are going to be almost transformed or put out of business by organizations that know how to deliver telehealth in a cost-effective way. It’s going to seem archaic to go to the doctor’s office in most cases. There will still be some need to go there, but the need for doctor’s offices is going to shrink, and the capabilities of delivering remote health care are going to grow. Some brick-and-mortar facilities will figure out how to deliver good health care. They will survive, but others won’t, and the doctors and nurses who work for those will end up being employed by direct-to-consumer companies.

It’s not that we won’t need doctors and nurses — we’ll still need them — but under what type of an economic and organizational structure will they be working? Will they be working within brick-and-mortar buildings, or will they be working in telehealth organizations? It’s going to be the latter, just like some sales jobs have migrated from stores to online services. The digital transformation in this world is going to affect medicine and to say that a patient is not able to partake in digital health is to say that they are missing opportunities.


For more information:

David C. Klonoff, MD, can be reached at