A companion to the JMIR editorial “From Innovation to Infrastructure: Why Digital Behavioral Health Still Struggles to Scale.”

In May of 1886, over roughly thirty-six hours, thousands of railway workers across the American South moved one rail inward by three inches across more than 11,500 miles of track.

The locomotives did not suddenly become faster. Freight cars did not fundamentally change. Labor costs remained the same.

By the following morning the work was done. Trains that had previously stopped at regional boundaries because of incompatible track gauges could suddenly move seamlessly across state lines. Nothing had been invented. The pieces had simply been made to fit.

The breakthrough was infrastructure.

Digital behavioral health faces a strikingly similar problem. Over the past two decades, the field has produced a growing catalogue of validated interventions: digital therapeutics, self-guided programs, AI-supported systems, evidence-based tools. Many of them work remarkably well, and researchers have demonstrated efficacy across a wide range of behavioral and mental health conditions.

And yet most of them never reach the people they were built for.

Off the Rails?

Clinics, insurers, employers, student health centers, nonprofits, and research groups continue to invest in – and receive funding for – short-term pilots. The trouble with pilots is that they tend to run on disconnected onboarding systems, temporary funding, and fragmented workflows, with continuity models left out of the initial scope. When the pilot ends, continuity often ends with it.

Even successful pilots are fragile. Organizations change vendors. Priorities shift. Project champions move into new roles. And validated tools that worked beautifully in a trial struggle to become a routine part of how care is delivered.

In my own work deploying behavioral health programs across health systems, NGOs, and governments, I keep running into the same walls. The question is almost never whether the intervention works, it’s whether the environment around it is built to let it keep working, continuously, consistently, and at scale.

At its core, this is a coordination problem. It’s a lack of infrastructure.

From Programs to Infrastructure

Like the railways before standardization, digital behavioral health operates across a fragmented landscape of incompatible onboarding systems, identity frameworks, reimbursement models, regulatory environments, clinical workflows, and data structures.

Every boundary introduces friction. Every mismatch creates operational overhead. And every workaround imposes a cost that compounds across the patient journey.

Most digital behavioral health initiatives are still built as programs rather than infrastructure. They are organization-specific, temporary, pilot-based, tied to short-term funding, dependent on local workflows, and disconnected from the broader systems of care around them.

This is not a criticism of pilots, or of innovation. Pilots are necessary. Innovation remains essential. But for years now, health systems have kept encountering the same underlying issue: validated interventions are introduced into environments that lack the operational infrastructure required to sustain them.

The field has become very good at building tools. It has been far less effective at building the infrastructure required to coordinate them.

The clearest evidence of that gap is what happens to the signals these systems already generate. Disengagement is often visible in the data but disconnected from any workflow able to act on it. Symptom escalation can unfold gradually across fragmented systems without triggering a response until acuity is severe. The signals tend to exist. The infrastructure required to recognize and respond to them consistently often does not.

What Infrastructure Might Actually Look Like

If digital behavioral health is to function as part of routine care, rather than a collection of isolated programs, the infrastructure beneath it will need to evolve in several practical ways.

Over time, that may include:

• interoperable onboarding and identity systems
• portable continuity that follows a person across providers and organizations, languages and borders included
• standardized measurement approaches
• reimbursement structures tied not only to encounters, but to engagement and outcomes
• workflows capable of responding earlier to deterioration or disengagement
• governance that earns trust and holds up as systems learn and adapt, because people engage honestly only with systems they trust
• systems designed for longitudinal continuity rather than isolated episodes of care

Infrastructure does not replace clinical care. It creates the operational conditions that allow evidence-based interventions to remain accessible, coordinated, and sustainable in the real world.

History suggests that systems do not truly scale when individual components improve in isolation. They scale when the infrastructure beneath them lets those components work together. Digital behavioral health may now be arriving at that same realization.

The Binding Constraint

For a network like eMHIC, focused on global access and real-world impact, this reframing is more than semantic. The countries and communities with the greatest need are precisely the ones where infrastructure – not innovation – is the binding constraint. They do not lack evidence-based programs. They lack the delivery layer that would let those programs reach people consistently, safely, and at scale.

The full argument, and the research behind it, is in the JMIR editorial “From Innovation to Infrastructure: Why Digital Behavioral Health Still Struggles to Scale” (https://www.jmir.org/2026/1/e97118).

But the operational takeaway is simple enough to state in one sentence:

Innovation creates tools; infrastructure determines access.

The field has been generous with the first and neglectful of the second – and the gap between what works and what reaches people is the direct result.

Trevor van Mierlo, DBA, is a digital behavioral health consultant and the Founder and Scientific Architect of the Evolution Health platform. Follow Trevor’s writing and published research on LinkedIn: https://www.linkedin.com/in/tvanmierlo/