Designing digital health applications for climate change mitigation and adaptation

Digital health, an integrated approach using digital technologies and platforms to improve health care outcomes, has emerged as a key tool to reduce health care's approximately 5% share of global greenhouse gas emissions1 and to address the impact of climate change on health. When the National Health Service (NHS) England committed to reducing its carbon footprint to net zero by 2040, it indicated that digital transformation is central to delivering low carbon health care models.2 However, this mitigation of emissions from health care is yet to be realised due to different maturity levels of digital health technology (DHT) integration worldwide.3 So, how can low carbon models of care be achieved through digital health, and what are the implications for digital health service design and delivery? How can digital solutions be adapted on the principles of sustainability, ecology, and equity in order to effectively address the impacts of climate change on health?

Mitigating the carbon impact of digital health technology

Even though the direction of NHS England suggests that DHT can assist health care systems to reduce their carbon footprint,2 the environmental effects of DHT are challenging to address, as they go beyond the confines of hospitals and traditional care settings. These effects touch on the digital health consumer, the supply chains of DHT production and use, multiple health mobile phone applications (apps) and the internet of things (a network of objects with sensors), activity trackers and telehealth equipment, and data transmission and storage.4 Subsequently, we must consider DHT interventions as an ecosystem of their own, requiring environmentally sustainable production and recycling processes reflective of the principles of climate justice.5 In this ecosystem, health services have an impact on environmental sustainability through their choice of DHT. Every DHT can contribute to this impact, such as telehealth and electronic medical records (EMRs), consumer use of DHT applications for health self‐management, and even use of environmental health sensors monitoring air quality, for instance.6

Rapid growth in health data demand and digital devices add to these emissions. Health care data account for nearly 30% of the world's total data,7 and the storage of these data in cloud servers produces a substantial carbon footprint. Here, the solution lies in green (energy‐ and resource‐efficient) cloud computing and renewable energy technologies as key considerations for sustainable data management.8 The digital health sector also needs to conduct environmental audits of DHT and develop strategies to reduce the adverse environmental effects of DHT initiatives.9,10 This requires those working within health care systems to acknowledge the contribution of DHT and services to carbon emissions. The 2021 report of the Royal Australasian College of Physicians on climate change and Australia's health care systems mentions the role of telehealth but not DHT's contributions to carbon emissions.11

Digital health tools to assist adaptation to the health impacts of climate change

Critically, digital health has the potential to directly contribute to climate change adaptation and mitigation.3,5,12 In the context of Australia, inhabitants are exposed to diverse climatic conditions, such as drought, heatwaves, floods and bushfires. Smoke‐related air pollution from the 2019–20 south‐eastern Australia bushfires reached hazardous levels across rural and metropolitan areas and affected neighbouring New Zealand.13 Flooding throughout the country decimated local communities, affecting local health care systems and food security when trade routes were washed away.14 In this situation, DHT has a role in delivering health care in difficult‐to‐reach settings and monitoring and mitigating localised environmental health‐related impacts due to natural disasters. For example, data can be leveraged on an individual basis through apps such as AirRater, which monitors and predicts the levels of air pollution and acts as an early warning system for individuals who are most vulnerable to pollen and air pollutants.15

The Riyadh declaration on digital health reinforced the importance of digital technology, including surveillance technology, data and innovation for resilient global health care systems.16 Digital surveillance technology is of growing importance as Australia sees the emergence of pathogens previously not endemic to the country (eg, the Japanese encephalitis virus), which is attributed to the impacts of climate change on vector‐borne diseases.12,17 Throughout the coronavirus disease 2019 (COVID‐19) pandemic, Australian health care services adapted rapidly to virtual care models enabled by telehealth and DHT applications. They served the dual purpose of reducing carbon emissions through decreased travel and increasing the availability of general and specialist care to rural and remote communities.11,18 These applications are environmentally adaptable to combat the escalating health impacts of climate change (Box).

Reframing digital health for a sustainable and more equitable future

Digital health has an unparalleled opportunity to become more adaptive for climate action and resilience through a focus on sustainability, equity and the interconnection of digital health and the environment. We consider the following three enabling areas for adaptation and provide supporting examples in the Box.

Sustainable digital infrastructure and digital health technology products

Sustainable DHT products are repairable, recyclable, biodegradable and designed to have a minimum ecological effect across their life cycle.9 The NHS net‐zero actions include digitally enabled care models and building net zero into digital maturity frameworks.20 Ideally, this includes connectivity of digital health care systems and better enablers of digital access to care providers to minimise environmental impacts on health (eg, before, during and after disasters).

Innovation in digital health needs to shift accordingly to avoid corporate practice patterns and introduce environmentally focused design‐based approaches. Environment‐centred design, for instance, brings to the foreground new design thinking at the intersection of human‐centred design, usability, ecology, and sustainability science.21 The Green guide for health care is an example of a sustainable design toolkit integrating environmental and health care principles and practices into facility planning, design, construction, operations and maintenance.22

Interconnecting digital health technology with ecological determinants of health

Human health is inextricably linked to the health of the natural environment. It is imperative we recognise ecological determinants of health, such as threats to the natural environment and health promotion of the human health co‐benefits of protecting planetary health.23 The concept of One Health integrates and unifies the approach to sustainably balance and optimise the health of people, animals and ecosystems, including the potential digital health connections across these systems.24 To facilitate and improve interactions between One Health and digital health, there is a need to deliver near real‐time data‐driven contributions across systems of medicine and ecology,25 such as the use of public‐generated data in air quality monitoring15 and algorithms that are public health‐focused, which can respond to outbreak scenarios and emergency management systems.12 The intersections of digital and environmental health literacy are equally crucial to promoting and understanding climate change adaptation.26

Addressing inequity gaps

There is an unrivalled opportunity to address inequity gaps by responsibly redesigning digital health for climate change adaptation. Globally, a persistent gender gap in access to digital technologies remains; there are still 264 million fewer women than men able to access mobile internet.27 With the COVID‐19 pandemic evolving across the world, there has never been a more urgent time to deal with this issue. Furthermore, a documented link exists between climate change adaptation and the advancement of gender equity, whereby tangible action on one has a direct impact on the other.28 Addressing the digital gender divide can empower women to directly contribute to the creation of digital climate solutions. In Australia, climate change presents an equally critical opportunity for redressing and empowering Aboriginal and Torres Strait Islander communities to lead climate action planning based on their traditional and historical knowledge of the country.29 Furthermore, the COVID‐19 pandemic has increased health care inequity for disadvantaged and marginalised people, including older people, individuals with disabilities, and ethnic minorities, highlighting the necessity to implement solutions that bridge the digital divide and adapt DHT interventions to better support these groups.18

This critical opportunity to develop climate resilient, adaptable DHT solutions to address the ongoing health needs of people displaced by climate change‐related disasters must be seized. In Australia, this group experiences a loss of continuity of care due to a lack of an integrated EMR accessible from different health systems and geographical areas. How DHT interventions deliver when natural disasters destroy connectivity is a system vulnerability that must be addressed. The World Health Organization's guidelines on DHT interventions focusing on the inequity gap and reaching at‐risk populations sustainably may be of value here.30

A call for action

Climate change threats are increasing, and we must focus on adaptation and mitigation in all areas of health care. Digital health can positively contribute to climate action if implemented and maintained with environmental sustainability in mind. At the minimum, environmentally responsible digital health depends on transformation of care models and health system infrastructures to embed “green” approaches to routine practice along the continuum of design, implementation, evaluation, and consumer use.9 DHT is inevitably one strand in a process of adaptation to climate change impacts, and this transformation lies within wider policy environment and health care contexts, which may require change or adaptation. The current gaps call for a more rigorous commitment to forms of climate justice and empowering approaches as integral to the process.3,5 Health care professionals and consumers must be part of this transformation at every level. On an individual level, clinicians must be suitably aware and motivated to address these challenges through their own education and then educating and empowering their colleagues to create change.31 On a system level, the key to success is in interdisciplinary approaches involving all stakeholders in expanding sustainable and impactful DHT interventions through responsible, equitable design, and in assisting health care professionals in accurately measuring and mitigating the impact of these interventions on the environment.5,10,12