Findings
The DHCoE works to strategically advance science and evidence for digital health technologies (DHTs).
Key areas of focus include Artificial Intelligence / Machine Learning (AI/ML) in Software as a Medical Device (SaMD), Cybersecurity, Augmented Reality (AR) and Virtual Reality (VR), and Wireless Medical Devices.
The DHCoE develops and publishes Guidances with Digital Health Content and maintains a Digital Health Policy Navigator to provide clarity on regulatory policies.
Digital health technologies are acknowledged as having the potential to facilitate decentralized clinical trial activities and allow for continuous or frequent measurements of clinical features remotely.
Programs and initiatives include the Software Precertification (Pre-Cert) Pilot Program, the Regulatory Accelerator, and the Diagnostic Data Program.
The center is also involved in international harmonization on device regulatory policy and standards.

Recommendations
The DHCoE recommends that stakeholders, including sponsors and DHT manufacturers, engage with the agency early to discuss the use of DHTs in drug development or for decentralized clinical trials (DCTs).
Stakeholders are encouraged to use the Digital Health Policy Navigator tool to assess whether a particular software function meets the device definition and is the focus of FDA oversight.
The DHCoE emphasizes the need for a patient-centered approach for AI/ML-enabled devices that considers issues like usability, equity, trust, and accountability, and promotes transparency.

Regulatory Considerations
The DHCoE's work includes innovating the regulatory paradigm for digital health, moving towards models that may include shifting scrutiny from the pre-market to the post-market phase and focusing on the capability of firms (Software Pre-Cert Pilot Program).
The FDA has committed, as part of PDUFA VII, to activities such as publishing a Framework for the Use of DHTs in Drug and Biological Product Development and establishing a DHT Steering Committee.
The center provides information to help determine the regulatory status of various digital health products, such as Software as a medical device (SaMD), mobile medical applications (MMA), and General Wellness products.
Submissions for products with device software functions must include recommended documentation for the FDA's evaluation of safety and effectiveness.
For questions regarding upcoming premarket submissions, stakeholders are directed to contact the appropriate review division through a Q-submission.

Findings
Digital health measures for ADRD must align with patient and care partner priorities, including functional daily activities such as remembering object locations and maintaining speech fluency.
Sensor placement, data collection modalities, and algorithmic interpretation significantly impact the accuracy and reliability of digital measures.
While digital cognitive and behavioral assessments have strong potential as clinical endpoints, standardization is needed to ensure regulatory acceptance.
Sleep and mobility disruptions in ADRD can be measured with actigraphy, EEG, and ambient sensor-based approaches, but usability considerations are crucial.
Metadata, including environmental conditions and patient comorbidities, must be accounted for to ensure valid interpretations of digital measures in both research and clinical practice.

Recommendations
Researchers and technology developers should adopt standardized ontologies for digital measures to improve consistency across studies and regulatory submissions.
Digital biomarkers should be selected and validated with reference to patient and care partner needs, ensuring they reflect meaningful aspects of health.
Considerations such as sensor placement, data processing methods, and cultural neutrality of cognitive assessments must be accounted for in study designs.
Clinical trials should incorporate digital health technologies as both exploratory endpoints and potential screening tools for ADRD progression.
Further research is needed to refine algorithms for sleep, mobility, and speech-based digital biomarkers to enhance their predictive power for cognitive decline.

Regulatory Considerations
Digital measures of sleep and mobility have been recognized as potential clinical trial endpoints by regulatory agencies such as the FDA.
Standardized reporting and frameworks should be followed to ensure interoperability and data integrity in digital health studies.
Developers must document and validate scoring algorithms used for cognitive and behavioral assessments to meet regulatory expectations.
Data privacy and security regulations must be adhered to, particularly when collecting real-world behavioral and biometric data.
Ongoing validation and real-world evidence generation are necessary to establish digital measures as reliable clinical and regulatory endpoints in ADRD research.

Findings
OTS software introduces unique risks due to its general-purpose design and lack of lifecycle control by medical device manufacturers.
Comprehensive testing and risk management are essential to mitigate safety hazards associated with OTS software in medical devices.
Regular updates and maintenance are critical for managing obsolescence and ensuring long-term safety and effectiveness of OTS components.
Networking and interoperability of OTS software pose additional risks related to data integrity, cybersecurity, and scalability.
Enhanced documentation is required for high-risk devices incorporating OTS software, especially those involving AI or ML functionalities.

Recommendations
Provide comprehensive descriptions of OTS software, including version details and system specifications.
Conduct thorough risk assessments and include mitigation plans in premarket submissions.
Perform rigorous testing, including integration and regression testing, for OTS software components.
Establish mechanisms for continued maintenance, support, and version control of OTS software.
Ensure that device labeling includes warnings and specifications related to OTS software compatibility and restrictions.

Regulatory Considerations
Adherence to 21 CFR Part 820 Quality System regulations, including design controls and purchasing controls for OTS software.
Submission of a risk management file and traceability documentation linking risks, design requirements, and testing outcomes.
Compliance with premarket submission requirements, including 510(k), IDE, and PMA applications, as applicable.
Use of device labeling to communicate hardware and software compatibility and restrictions to users.
Development of beta testing and investigational plans for clinical studies involving OTS software.

Findings
The use of Intended Use and Indication for Use is crucial for digital health products to ensure the product is used appropriately and effectively to meet the needs of the intended population. This information helps establish clear expectations for a product's performance and safety, facilitates regulatory approval, and ensures compliance. The Intended Use provides a general description of the digital health product's purpose or function. The Indication for Use describes the disease or condition the device will diagnose, treat, prevent, cure, or mitigate, including a description of the patient population. A change in a product's indication for use from general to specific usually results in a narrower indication concerning function, target population, or disease entity. Levels of specificity for diagnostic and therapeutic products can be categorized, ranging from the identification of a physical parameter (most general) to the identification of an effect on the clinical outcome (most specific).

Recommendations
The Intended Use statement should include the name of the product, the medical purpose, and what it is trying to do for the user. The Indication for Use statement should include the name of the product, the specific condition or disease state it is addressing, the patient population being targeted, what the product features do, whether other technology components are used with the product, and whether it is for "prescription" or "over-the-counter" use. Developers should characterize the users (e.g., by age, knowledge, or language) and describe the usage context (e.g., hospital ward, emergency room, web-based app). The Indication for Use statement should clearly state the product's clinical capabilities and what it is not intended for (e.g., not intended to provide a diagnosis or replace traditional methods).

Regulatory Considerations
The information provided in the Intended Use and Indication for Use statements is used to inform the product's design and development, as well as to guide regulatory decisions about its approval and marketing. Defining these statements facilitates the regulatory approval process and helps ensure compliance with relevant regulations and standards. The FDA defines the levels of specificity as a qualitative ranking of the proposed indications for use. The document provides examples of FDA's "Indications for Use" from submissions, such as the use of an Atrial Fibrillation History Feature, illustrating the necessary detail for regulatory submissions like a 510(k).

Findings
Digital technologies face challenges across scientific, clinical, technological, business, ethical, and regulatory domains.
Current testing paradigms are inadequate for identifying meaningful changes in early-stage Alzheimer's disease.
Complex digital tools may not be suitable for all trial participants due to varying technology, motor, or cognitive skills.
Ethical issues such as privacy, data sharing policies, and informed consent are significant concerns.
The regulatory path for digital medical devices is unclear and needs further development.

Recommendations
Develop more sensitive and specific diagnostic tools for early-stage Alzheimer's disease.
Create adaptable and user-friendly digital tools suitable for diverse populations.
Address ethical concerns by establishing clear privacy and data sharing policies.
Engage with regulatory bodies early to understand the regulatory landscape.
Integrate digital tools into clinical trials alongside traditional measures to advance the field.

Regulatory Considerations
The regulatory path for digital medical devices is currently unclear and needs clarification.
Developers should follow design control methods and ensure compliance with relevant regulations.
Early engagement with regulatory agencies is recommended to speed up development and approval processes.