Service design, public engagement and the necessary components for digitisation

The range of ways in which technology can be used to support and improve health and social care is vast. From artificial intelligence hitting the news to the efforts around integrating NHS trusts and systems, there’s an awful lot happening in the health tech community.

Here, we’ll be narrowing it down to explore three studies on different aspects of digital health from recent studies and research.

“Digital tools are only as effective as their integration with the people and processes that work with them”

“The digital transformation of our health care system will require not only digitisation of existing tools but also a redesign of our care delivery system and collaboration with digital partners,” the authors state in a study recently published to JMIR Publications. They note that traditional patient journeys are reactive to symptom presentation and can be delayed by healthcare system-centric scheduling, which can lead to poor experience and avoidable adverse outcomes.

Looking to the future, the authors state: “Patient journeys will be reimagined to a digital health pathway that seamlessly integrates various care experiences from telemedicine, remote monitoring, to in-person clinic visits… To design and implement digital health pathways at scale, enterprise health care systems need to develop capabilities and partnerships in human-centred design, operational workflow, clinical content management, communication channels and mechanisms, reporting and analytics, standards-based integration, security and data management, and scalability.”

In the study, entitled ‘Digital Health at Enterprise Scale: Evaluation Framework for Selecting Patient-Facing Software in a Digital-First Health System’, the authors propose a set of criteria from design to technical requirements that focus on the capabilities needed for an enterprise healthcare system to implement digital health pathways at scale.

The first criteria is that the system should have human-centred design; the authors call this “the creative approach to problem-solving that directly engages with the people for whom the design is intended” and add that it is “core to defining the development of patient-centred digital care pathways.” They recommend starting with a detailed service blueprint to create a human-centred representation of the relationships among different service components, such as people, props and processes. This tool can then visualise organisational processes in order to better develop services that provide desirable and effective user experiences.

On a similar note, the next factor within the criteria is operational workflow. “Digital tools are only as effective as their integration with the people and processes that work with them,” the authors state. They add that ensuring that the digital tool provides an efficient user experience will ease its integration into the clinical workflow.

Next, the authors highlight clinical content management and communication channels and mechanisms. On the first, they acknowledge that content creation (such as patient education materials and clinical decision algorithms) are expensive and time consuming. A system should decide how much they would like to own and if they plan further development. “Important differentiation aspects of clinical creation include the ability for the health enterprise to customise content using a friendly, nontechnical interface, guidance from vendor clinical support staff, and speed to develop or modify care pathways. It is also important to define who owns any intellectual property created during pathway development at the start of the vendor relationship.” On the topic of communication channels and mechanisms, the authors emphasise that the digital care pathway can place patients at the centre of their care by empowering them with tools to communicate about the state of their health, in variety of formats. “As heath care systems move beyond hard copies of patient education materials,” they say, “they must take a comprehensive approach to digital delivery, which can include EHR portal, secure messages, email, SMS text messages, web content, videos, public social media engagement, and personalised chatbots.”

Next, the authors note the importance of reporting and analytics, highlighting that a digital health intervention generates a significant amount of data and frequent reporting is critical to assess any clinical and operational changes, in addition to analysing how effective patients are finding the tool.

Then they move onto standards-based integration, stating that integration of clinically relevant information ensures visibility, decreases the cognitive burden and reduces manual errors. They stress the importance of evaluating possible vendors for their ability to carry out integration and also note that integration is not just clinical, with third parties such as transportation, laboratories and payment also interfacing with patients and providing an opportunity to remove frictions.

The penultimate criteria focuses on security and data management, with the authors stating that the implementation team will benefit from having a predefined checklist and buy-in from stakeholders. The checklist could include business associate agreements; privacy; risk; legal internal review; IT security review; data management and retention agreements; technical service level agreements; required uptime; support responsibilities and infrastructure; and downtime procedures. In addition, with regards to vendors, the authors say: “As partners, the team should create an understanding of what patient data are being accessed and how and who owns the underlying insights generated.”

Finally, the authors touch upon scalability. Whilst a digital pathway may start as a pilot for one patient journey within one clinical condition, they note that essentially the goal is “to eventually service all touchpoints within the care journey across various clinical conditions. When selecting a vendor or platform, it is critical to keep the long-term growth in mind: if our programs are wildly successful, can this platform and vendor meet our enterprise-level needs?” Technical robustness must be evaluated to ensure that the platform is dependable, and databases and the server should be able to grow with the needs of the digital tool.

Citation: Shapiro M, Renly S, Maiorano A, Young J, Medina E, Neinstein A, Odisho AY
Digital Health at Enterprise Scale: Evaluation Framework for Selecting Patient-Facing Software in a Digital-First Health System
JMIR Form Res 2023;7:e43009
doi: 10.2196/43009 PMID: 37027184

“Attract, adapt and actively immerse the user” 

Building on some of the points raised in the study above, next we’ll take a look at a Frontier article entitled ‘Engaging patients and citizens in digital health technology development through the virtual space.’

“Digital technologies are increasingly empowering individuals to take charge of their health and improve their well-being,” the authors begin. “However, there are disparities in access related to demographic, economic, and sociocultural factors that result in exclusion from the use of digital technologies for different groups of the population.” In order to “foster responsible innovation and optimal use of digital health by all, including vulnerable groups”, the authors emphasise the importance of patient and citizen engagement as an essential component in the research strategy.

Firstly, the article states, in order to achieve the goal of active engagement, it is necessary to foster an inclusive environment in which all those involved in the research process understand the value of shared knowledge. “Patients and public partners can take meaningful and key roles in research by supporting access to peer networks and difficult to reach groups and peer-to-peer recruitment,” the authors point out. “This can also apply to the development of useful and adaptable digital technology intended for patients.” In order to increase adoption of those digital technologies, the authors say it is “essential” to enhance and encourage active participation in technology co-creation.

In order for a digital tool to be useful and effective, the article continues, its features must have the potential to “attract, adapt and actively immerse the user in its content”. However, with several studies noting limited effectiveness and eventual abandonment of technologies if intended users do not use tools as they were intended, design, appearance and functionality are “important precursors to user engagement. These factors encourage an effective and behavioural connection to the proposed tool.”

With this in mind, the authors developed Virtual Community of Patients and Citizens Partners (COMVIP), a digital tool co-created with patients and public experts, founded on the principles of equity, diversity and inclusion. Acting as a base of citizen expertise, COMVIP brings individuals from different backgrounds and literacy levels, living in vulnerable situation, together. They can share knowledge and experiences whilst actively contributing to the development of innovative strategies and health technology assessment. A co-creation process was implemented to ensure that different perspectives were integrated into the COMVIP platform development, and then a prototype was presented to the group with everyone invited to comment and propose possible improvements.

The researchers found that the prototype was positively welcomed and feedback was gathered around better user experiences and easier navigation, with the public sharing desire for additions such as user stories, video clips to demonstrate use, and the additional of useful links. The feedback was then reviewed according to significance and feasibility to guide decision choices about how to improve the platform, with the research team to conduct an improvement iteration of the platform according to the feedback before presenting a final version to the group to evaluate their satisfaction.

“Through online workshops and showcases, people from various backgrounds can engage in the co-development of digital health solutions adapted to their needs,” the authors say, adding that “successful patient engagement incorporates inclusive mechanisms and processes that allow patient and public involvement at all levels of the research process”.

They conclude that COMVIP supports patient and public engagement successfully in its research methods and co-creation design process, and note that the project “effectively empowers and includes stakeholders through every research and development stage while valuing stakeholders’ key role through shared personal experiences and appreciation.”

As a final note, the authors acknowledge that participant engagement towards the platform will be key to its successful adoption, implementation and sustained use, and share their ambitions for COMVIP to “help develop knowledge about the needs and challenges of vulnerable groups with respect to their acceptability of digital technology, beyond technical considerations, and about the factors that can promote digital health literacy among these groups.”

Citation: Barony Sanchez RH, Bergeron-Drolet L, Sasseville M and Gagnon M (2022) Engaging patients and citizens in digital health technology development through the virtual space. Front. Med. Technol. 4:958571. doi: 10.3389/fmedt.2022.958571

“The essential components for digitalisation success”

‘How digital transformation can accelerate data use in health systems’, published in Frontiers last month, shares the researchers’ findings from a study documenting and analysing the experience of five African countries in digitisation: Burkina Faso, Ethiopia, Malawi, South Africa and Tanzania. Through examining the different approaches of these countries, the researchers aimed to “develop a holistic model of digital transformation for data use that identifies what the essential components for digitalisation success are and how they interact with each other.”

They identify a number of key components of digital transformation believed to accelerate and improve data use in the health sector, and enabling factors for each.

The first is to engage stakeholders and develop digital health champions, including coordinating and aligning stakeholders. In many cases, the researchers note, stakeholder engagement and coordination relied on working with existing technical working groups or forming new ones to solve issues and implement solutions. A particular finding was that relevant individuals from outside the health industry should be included, such as local government authorities.

Secondly, establish clear, strong governance structures appropriate to the country’s context and needs. The lack of a governing body to oversee the review, approval and coordination of different projects was noted as a key challenge to implementing new solutions. They highlight how Tanzania established a project governance team including partners and funding representation to manage work across multiple agencies, whilst Ethiopia and Malawi adopted an embedded approach that placed project implementation staff within government operations, which helped build champions and supported coordination.

The next component is to apply user-centred design approaches in identifying and implementing digital tools and systems. The study shares numerous ways in which this can be done, based on its research. In Malawi and Burkina Faso, the researchers state, focus groups were held with health workers to gain insight in user needs. In South Africa, consortium meetings were held to discuss planning and implementation of digital health solutions. Meanwhile, Tanzania used an agile methodology in strategic planning, working directly with users to develop systems and tools.

The fourth is to improve the training of the health workforce to build capacity, with the most of the countries studied including some form of capacity-building in their activities to improve health workers’ use of digital tools and data. In Malawi, for example, government and partners launched a learning centre to provide technical and professional support; Ethiopia and Tanzania worked with universities to develop and standardise training curricula.

Next, the researchers highlight the importance of ensuring that data is collected, shared and monitored across systems. In the countries studied, this was primary done by establishing data standards, inventorying systems in use, and increasing the interoperability of different systems and tools. For example, in Tanzania, a health enterprise architecture was developed by the government to serve as a conceptual blueprint for the country’s digital health system structure and operation.

Finally, the study emphasises how funding must be aligned. All five countries included donors in the stakeholder engagement to varying degrees, the researchers point out, adding: “When donor coordination under a common plan or vision is lacking, investments may not align with achieving the country’s digital health plans”. Strategies included including funders and donors in technical working groups or creating a digital health investment roadmap that recommended areas for investment along with financing and cost guidelines.

Discussing their findings, the authors point out that whilst their model builds upon existing frameworks such as the World Health Organisation’s eHealth strategy, it also introduces “two new critical factors for advancing data use: the data use ecosystem and change management strategies that were not included in the original set of building blocks.”

As a final note, the authors share a number of key actions to be taken in order to improve digital transformation in countries: to engage stakeholders and improve leadership; to cultivate a culture of data use throughout the  health system; to strengthen governance structures; to increase evidence-based planning; to improve the design of health systems; and to align and sustain funding efforts.

Citation: Werner L, Puta C, Chilalika T, Walker Hyde S, Cooper H, Goertz H, Rivera Hildebrand M, Bernadotte C and Kapnick V (2023) How digital transformation can accelerate data use in health systems. Front. Public Health 11:1106548. doi: 10.3389/fpubh.2023.1106548