Digital is the new normal. Digital technologies allow us to access information (sometimes of variable quality) almost instantly, trigger actions remotely (such as transferring money to anywhere in the world), and even communicate with a huge audience of people that we have never met (Twitter™ and other so- cial media platforms). Where do health care and health care professionals sit in all of this? At times, it looks like health care is the one area of human activity that is the most resistant to change.

The term "eHealth" or "digital health" covers the use of information and commu- nication technologies and services in health. These technologies may be used by health care institutions, health care professionals, and, of course, patients/ citizens. mHealth is a relatively new subdomain of eHealth that involves mobile phones as well as the more complex applications (apps) that are available for smartphones. It is a rapidly expanding field: an estimated 2.3 billion people world- wide own a smartphone, and half of these people are using health or lifestyle/ wellbeing apps. The distinction between health, medical, lifestyle, and fitness information is becoming increasingly blurred, and it is difficult for health care professionals, regulators, and policy makers to keep up with the rapid changes happening all around us.

As cardiologists, we are generally early adopters of new technologies, but, in our day-to-day practice, we often struggle to know what to do when a patient shows us an app on their smartphone that has collected data on them since the last clinical visit. Can we trust the data? How do we import the data into the patient's electronic medical record even if we do trust the data? And, what happens if a lawyer challenges our use of the data if we make a decision that ends in an adverse event? Often there is little guidance to help us. Politicians strongly be- lieve that digital transformation (or "disruption") will ensure a better and more. efficient health (care) system. A previous European Commission Vice President, Neelie Kroes, is quoted as stating in 2014 that "mHealth will reduce costly visits to hospitals, help citizens take charge of their own health and wellbeing, and move
toward prevention rather than cure.", Not coincidentally, she also highlighted the economic benefits of supporting the "booming app economy and entrepreneurs." 

The World Health Organization has recently reviewed the progress of imple- menting eHealth solutions in the European area., On a positive note, the report identified clear evidence that there was an increased appetite for eHealth, with tangible progress in many countries. The majority of European countries had national strategies or policies for eHealth and national health information sys- tems. However, the report sounded a warning that eHealth requires far more than just the acquisition of technology and that initiatives were often derailed by the changes required on organizational processes and structures, staff roles, edu- cation, reimbursement, and culture. Also, a lack of a legal framework has often slowed progress down, and many projects have failed to convert from pilots to large-scale implementation.

Therefore, there is much promise. Maybe even hype. However, what might be some of the downsides? There is concern among regulators about data security, and among health care professionals about the legal issues: when new data becomes available 24/7, what happens if action is not immediately triggered? Who will look at the tsunami of data potentially available? Will we ever be allowed to "switch off?" How can we incorporate patient-generated data into our medical records and decision-making processes? How can we be sure that these data are valid and reliable? Which apps (if any) should we recommend or prescribe to our patients? 25 Ollect antiges 110011 Th The European Society of Cardiology is increasingly active in the digital health space. It has published a position statement and identified a roadmap for the organization. A digital committee has been set up to help accelerate and coordi- nate activities across its members and affiliated groups. At the Annual Scientific Meeting in Barcelona in August 2017, there was a "Digital Village" (in partnership with 4 years from Now [4YFN], a program of the Mobile World Capital Barcelona) where delegates could view start-up technologies from key digital health pio- neers. The key words were digital empowerment, digital transformation, and digital care innovation. Examples of such innovation included atrial fibrillation diagnostic technologies (ranging from wearables to apps), internet-based digital health data depositories, new remote monitoring systems, rehabilitation gaming systems, automatic echocardiogram reading software, and decision support tech- nologies for doctors and patients.

Cardiologists strongly embrace evidence-based medicine, and they are most com- fortable with large randomized trials that clearly demonstrate improvements in survival, reductions in hospitalization rates, and/or improvements in quality of life. Such robust assessments ensure that we adopt innovations that truly make a difference, but the pathway from idea to implementation is long and very ex- pensive. Digital solutions do not fit easily into this framework, and many of the key stakeholders (doctors, regulators, reimbursement authorities) struggle with how to value digital innovation. Some things are likely to happen without robust evidence (increased electronic medical records and e-prescribing across borders) and some things are likely to be pushed into practice by popular demand (home- based monitoring of blood sugar, blood pressure, remote consultation), but other technologies do require robust evaluation (eg, artificial intelligence-based image recognition software for diagnostic purposes, implantable monitoring technol- ogies, decision support technologies, app-based triage replacing the general practitioner assessment). In recognition of these challenges, the Food and Drug Administration Center for Devices and Radiological Health in the US has set up a Digital Health Program, which "seeks to better protect and promote public health and provide continued regulatory clarity by fostering collaborations with digital health customers and developing and implementing regulatory strategies and policies for digital health technologies.", Other areas of the world are likely to follow shortly.

What is clear is that cardiologists cannot always just say "no" to disruption coming from digital innovation. We need to be part of the conversation, not only by sup- porting innovation to address unmet needs and improving outcomes and patient experience and convenience, but also by demanding robust evidence and a reg- ulatory/legal framework that clarifies what role these technologies should have in clinical practice. We need to work with all of the key stakeholders to navigate through these potentially choppy waters together.

The future is hopefully bright and undoubtedly more digital.