Digital Front Doors: Moving from Fad to Future

Author's Note: The views expressed below are my own and not affiliated with any organization

A few weeks ago, I was watching a medical drama on Netflix – New Amsterdam. A dialogue from the Medical Director of the hospital struck a chord with me – “There is no reason that healthcare has to be delivered in a hospital. In fact, patients are best served in an environment where they are made comfortable. By trusted members of their own community. Hospitals have to go meet patients where they are, not the other way around.”

Most of us have heard this before in some shape or form, but at the heart of it, it is about the health system providing its patients the services they need, where and when they need it and in a way that is easy to access. This is the crux of patient-centricity. The pandemic had a silver lining, where it accelerated the use of technology to deliver care (telemedicine, virtual care, remote monitoring, health apps, etc.), minimizing in-person visits and the risk of getting Covid-19. In addition to the adoption of these digital front doors, the pandemic inspired a few other changes:

• Increased sharing of data and its use in insight-driven decision-making: The use of data to inform strategic and operational (including clinical) decision making has accelerated at a rate never seen before. From leveraging data-driven models to power command centers for managing the supply and demand of Personal Protective Equipment (PPE) to increased use of Artificial Intelligence (AI) and predictive analytics for clinical decision making and population health management, health systems have enabled providers to share data and rapidly move from data-driven to insight-driven?decision making. This capability will likely remain an area of investment priority for health systems post-pandemic.
• Regional care planning: We have also witnessed health systems utilize their regional/provincial governance structures to manage the capacity in the system to deliver care for the population, establish standardized guidelines for delivering care to COVID and non-COVID patients, distribute and administer vaccines, etc. The health systems will need to sustain these governance models in order to move towards population health management.
• Better coordination and integration amongst providers: Healthcare providers have leveraged the pre-COVID foundation to build stronger relationships to coordinate care delivery for COVID patients. Further to the coordination, they have partnered with each other to adopt leading practices, deliver integrated health and social care services, and build new capabilities (e.g., Long Term Care homes building Infection Prevention and Control practices in partnership with hospitals).
• Agile and hybrid workforce models: Due to the pandemic, the health workforce had to learn how to be quick on its feet to adopt new practice guidelines, be more resilient, and become comfortable with technology and remote working environments. Moving forward, it will be important for healthcare providers not to lose the capability of working remotely and work towards sustaining a hybrid working model for their workforce.
• Increased modernization of healthcare organizations: Healthcare providers have embraced digital transformation and are increasingly realizing the importance of connecting their patient-facing functions with their other enterprise functions (i.e., middle and back-office functions). This has facilitated middle- and back-office transformation (e.g., HR, Finance, Supply Chain, Cyber Security, etc.) to modernize and integrate a provider’s enterprise and create a capability for enabling integration with other providers.

It was important to review the changes inspired by the pandemic because they will empower the health system and its workforce to adopt, scale and sustain the digital front doors.?

Now that we know the changes, let’s understand – digital front door. I have read different descriptions for the term, but at its essence, I think digital front door means – a digital-first approach to communicate, engage and care for patients, when and where they need it, throughout their care journey. A digital front door is essentially a platform that provides seamless, unified and technology-enabled access to the health system for citizens through various modalities – remote monitoring, virtual care, telemedicine, chatbots, wearables, health and social care applications (e.g., scheduling and triaging, COVID tracing apps, vaccine passport, etc.), patient portals, etc. It is much more than just virtual access to a family physician or remote monitoring of symptoms.

?Digital front doors can empower providers to deliver a seamless, meaningful and connected care experience for their patients that extends beyond the facilities to where they are and support their care at various points of their journey. The beauty of the digital front door is that it is aligned with two of the five pillars of the Canadian Healthcare Act – Accessibility and Portability. If the digital front door is implemented sustainably and equitably in the health system, it has the power to ensure access to care for all Canadians, no matter where they are. But health systems need to be careful because with increased adoption of digital front doors during the pandemic, we have seen the emergence of two new social determinants of health – digital health literacy and digital health equity.

The providers, government and technology vendors need to understand these two social determinants in order to successfully enable equitable access to health and social care for all Canadians. Before we move towards understanding what a digital front door means for the different stakeholders, let’s understand these two social determinants of health:

• Digital health literacy: To make the digital front doors accessible to all Canadians, they will have to be linguistically and culturally tailored to meet the needs of the diverse populations of Canada. Additionally, technology vendors, providers and the government will have to implement programs that educate Canadians on using the digital front door solutions and enhancing patients’ access to their health data.
• Digital health equity: In addition to improving digital health literacy, the government, providers and technology vendors will need to devise approaches to address the five main facets of digital health equity: technology access, technology literacy, implementation, payment models, and standard of care. Currently, only people who have access to a mobile or a computer can access virtual care or remote monitoring, resulting in inequitable access to health and social care services. To ensure equitability, the government and providers will have to invest in 5G and other infrastructure (e.g., easy access to wireless internet, health kiosks at pharmacies, etc.) for remote and vulnerable populations and educate them on how to use these resources. In addition to investing in technology, the government and providers also need to be culturally sensitive, build trust and account for other considerations to equitably provide a digital front door for aboriginal, Inuit, and other diverse populations.

“Digital health equity is a step towards health equity and is essential for our success and the sustainability for digital health overall.” – Dr. Jorge Rodriguez, a health technology equity researcher and hospitalist at Brigham & Women’s Hospital, Department of General Internal Medicine

A prime example of a digital front door is the Niagara Health Navigator App. The mobile application is meant to provide Niagara’s citizens with a digital health ecosystem that protects patient privacy and security, connects them to their health data and enables digital access to health care service through a single login. While the App will evolve to achieve this vision, it is a step in the right direction, especially with a partnership between a technology vendor – IDENTOS and a hospital – Niagara Health. The hospital is scaling the partnership into the community to provide Niagara’s citizens access to out-of-hospital care services and will potentially be an integral part of their Ontario Health Team model of care.

Now that we know what digital front doors are, let’s understand what they mean for patients and what providers, and what governments and technology vendors need to do in order to sustainably implement a digital front door.

What does a digital front door mean for patients?

I am a firm believer in the saying - a picture speaks volumes louder than words. I think that the graphic shows what digital front doors mean for patients. It is a means for providing equitable and easy access to various healthcare services. The goal is to put?patients, families and caregivers at the center and via a few core principles (the second circle) identify the various modalities (the third circle) through which they will have access to the healthcare services they need (the fourth circle). These principles, modalities and healthcare services mentioned in the graphic are meant to illustrate an example. Depending on the health system and its population’s needs, it could include other principles, modalities (e.g., e-prescription) and healthcare services (e.g., assisted living, rehabilitative care, etc.)

What do providers, governments and technology vendors need to do in order to sustainably implement digital front door solutions?

Providers need to work together to design and implement:

• Population health management programs that provide access to health prevention and promotion services that enhance health and wellness of the population, reducing the need to access curative medicine (e.g., use of apps, wearables, etc. to connect with patients and share health and wellness resources);
• Patient-centered and digitally enabled care pathways that support diverse patient populations throughout their care journey and provide health and social care services. The pathways will need to be enabled by effective and efficient care coordination processes (i.e., managing referrals, transition planning, etc.) and integration with clinical support services (e.g., diagnostics, pharmacy, etc.). The redesigned care pathways should provide on-demand and ongoing remote care, rather than episodic care delivery, wherever possible;
• Patient, family and caregiver representatives should be included in the care pathway redesign process to ensure that the patient’s voice is captured and inclusive of the diverse patient populations. For example, the redesign should account for a translator and other resources required to deliver care through the digital front door for people with disabilities;
• A patient education and engagement strategy that increases health literacy of patients, families and caregivers; To develop this strategy, the providers should refer to leading practices that allow the providers to build trust and effectively communicate with their patients. For example, develop a “webside manner” to effectively engage the patient virtually – i.e., maintain eye contact with the patient, use proper lighting so that the patient can see you, ensure there are no distractions in the background, etc.; and
• A strategy to employ, deploy, manage, train and retain an agile and multi-disciplinary workforce.

Further, the organizational functions and digital systems that support the providers and patients will need to be connected, aligned, data-driven, easy to access and secure.

Governments will need to design and implement:

• A national, health system-wide data and technology architecture that connects the existing technology solutions and allows integration of new solutions;
• A policy framework that enhances the adoption of digital health solutions and enables public-private partnerships, investment in an interoperable data infrastructure, and provincial workforce and patient digital health literacy programs. For example, the Association of American Medical Colleges (AAMC) has identified competencies required by medical students and professionals in the US to effectively deliver telemedicine. An example of investment in patient digital health literacy is the My Way Program under the Good Things Foundation that the Australian Digital Health Council funds. The Foundation has trained 232 digital health mentors across 71 community organizations across Australia to teach digital health literacy skills and improve digital inclusion;
• Payment and funding models that enable and sustain the use of digital front doors for providers;
• Guidelines to standardize digital front door interactions and process;
• A strategy for infrastructure modernization to enhance privacy and security and equitable access to digital front door solutions for all Canadians (e.g., a digital identity for every Canadian, 5G and wireless internet access, moving to cloud, etc.).

Technology vendors need to:

• Work with the government and providers to develop innovative, value-based funding models that increase adoption of digital front door solutions;
• Identify leading practices for implementing their solutions, allowing for economical use of resources for implementation;
• Develop educational resources for the healthcare workforce and Canadians to make the adoption process easier;
• Ensure that their solutions can integrate with the existing health and social care system’s digital infrastructure, enabling a seamless exchange of information.

The above changes will require time, trust and commitment. Even though some are long-term changes, there are a few things that providers can do within the next six to twelve months to scale and sustain the digital front door that they have implemented during the pandemic:

• Identify the needs of their patient populations and parts of their care journey that they can access through the digital front door;
• Identify key performance indicators that will measure the success of the digital front door. For example – digital health access and usage across sociodemographics, patient experience and outcomes, etc.;
• Redesign care pathways with a digital-first and stepped-care approach and in alignment with the desired patient experiences and service delivery goals;
• Identify processes that are a bottleneck in the current state and determine whether digital tools, such as automation, can be used to reduce wait-times and administrative burden and enable seamless patient experience;
• Conduct a gap analysis to identify capabilities and digital assets the organization needs to invest in;
• Reassess the data and technology architecture to ensure interoperability, scalability, and privacy and security;
• Develop an implementation budget and benefits realization model; and
• Educate the workforce on how to use the digital front door solutions to increase adoption and standardize their interactions with patients.

My question for you – What else do providers need to do in the next six to twelve months to scale and sustain their digital front doors?

Some reports and articles that inspired my thought process:

• https://policyoptions.irpp.org/magazines/january-2019/enabling-digital-health-care-solutions-canada/ ?
• https://www.fastcompany.com/90595833/with-hospitals-overwhelmed-by-covid-19-telehealths-time-is-here ?
• https://www.healthcareitnews.com/news/study-nyc-black-latino-patients-less-likely-white-patients-use-telehealth-during-pandemic
• https://www.fastcompany.com/90595833/with-hospitals-overwhelmed-by-covid-19-telehealths-time-is-here
• https://www.mobihealthnews.com/news/contributed-digital-health-and-opioid-use-disorder ?
• https://www.healthcareitnews.com/news/digital-health-literacy-social-determinant-health
• https://www.healthcareitnews.com/news/women-are-less-likely-use-video-telehealth-care
• https://www.healthcareitnews.com/news/digital-health-literacy-social-determinant-health
• https://www.healthcareitnews.com/projects/telehealth-remote-monitoring-and-wearables-are-transforming-care-delivery ?
• https://policyoptions.irpp.org/magazines/january-2019/enabling-digital-health-care-solutions-canada/
• https://www.telacare.com/blog/what-is-a-telemedicine-kiosk-and-why-is-it-the-future-of-health-care
• https://www.aamc.org/news-insights/what-every-doctor-needs-know-about-telemedicine
• https://www.miragenews.com/good-things-happening-to-support-digital-health-531756/