Health System- and Payer-Level Decision-Making Processes Influencing the Adoption and Sustainability of Patient-Facing Digital Health Tools: Qualitative Study.

Abstract

Patient-facing digital health tools such as mobile health apps, wearables, and digital therapeutics have expanded rapidly and show promise for improving chronic disease management. Despite increasing evidence of effectiveness, health systems and payers continue to face challenges integrating these tools into routine care. This study examined the decision-making processes of health system and payer leaders regarding the adoption and sustainability of patient-facing digital health tools within their organizations. We conducted semistructured interviews between August 2025 and December 2025 with nine senior leaders from a large Midwestern academic health system and affiliated payer organizations, including a provider-owned health plan and a state Medicaid program. Interviews explored digital health adoption decisions, perceived value and fit, barriers, and sustainability considerations, focusing on the adoption of an evidence-based mobile health intervention for alcohol use disorder as a use case. Transcripts were analyzed using thematic analysis with inductive and deductive coding. Four decision-making mechanisms shaped adoption and sustainability decisions: prioritization under organizational constraint, risk mitigation, operational fit, and value determination. These mechanisms describe how leaders navigate limited organizational capacity, reduce uncertainty, and protect against clinical, financial, and operational risks, assess whether tools can integrate within existing clinical and technical systems, and determine whether anticipated and measurable benefits justify adoption and continued organizational support. Adoption and sustainability of patient-facing digital health tools are shaped by dynamic organizational decision-making processes that often remain invisible to patients, clinicians, researchers, and developers. Making these processes visible may help better align digital health tools with the realities of the health care system to support implementation.