How To Make Digital Health Technology Work For You.

Lo Fu Tan MD,MS  and Ron Rubin, BS        

Summary:

C-suite executives of both payer and provider health care organizations and their operational and clinical leaders responsible for Digital Health strategy have the formidable challenge of deciding what to spend on and how to mesh this with legacy applications. All have technology that is minimally used or not at all, and replication of like-tools driven by specific clinical and business case uses combined with technological inflexibility.

Factors contributing to the problem include the considerable number of new products, limited evidence regarding efficacy and outcomes, significant investments required often without any return on investment, and multiple stakeholders not aligned with decisions and spending.

A solution would be to evaluate new (or old too) tech applications for their functionality and value, then use a standardized framework for its implementation.

Local and scaled steps can facilitate, support, and sustain a patient-centered application of the best technology in Healthcare.

The Point:

The experience of Healthcare can be unpleasant. Accessing and navigating the system to receive timely, high-quality, and affordable care is not easy for patients. Cumbersome operational processes and inefficient legacy tools cause clinicians to waste time and promote burnout. Stakeholders- including payers and members, clinicians and their patients, industry, government agencies, and non-profit organizations- crave a new paradigm that is smooth, seamless, and individualized. Technology is heralded as the means to make this happen through an end-to-end and fully integrated approach—all in a timely fashion under a cost-effective, viable business model. Despite the diversity of priorities amongst stakeholders, they can share a singular vision around technology. Digital Health, synonymous with Technology in Healthcare, is commonly defined as a convergence of digital technologies with Health, Healthcare, living, and society.1 Furthermore, our vision of Digital Health- a patient-centered application of the best available technology to further the Quadruple Aim of better patient experience, clinician engagement, affordability, and quality2- can undoubtedly be adopted by all users of Healthcare. The technology we are talking about are just tools to make Healthcare uncomplicated but always beginning and finishing with the patient in mind.

What is facilitating this drive for the digitalization of Healthcare? We believe that the phenomenon is mainly due to our inability to meet demand requirements. The general practitioner had it right by providing in-person care in the office or emergency department or hospital or home, wherever the patient needed it. This clinician knew the patient well due to 1:1 clinical encounters and continuity through follow-up, so it was very personalized. Care was relatively affordable as testing and treatment, and referrals and appointments were decided based on clinical necessity and less on profit and liability. However, the shortage of primary care physicians, even with nurse practitioners and physician's assistants added, has resulted in the erosion of this relationship as the gold standard of care. Virtual ways of communicating and "seeing" patients, although not ideal, are practical and can help.

There are countless technological tools that the health care system is deploying to improve the patient experience end-to-end. This effort preceded the pandemic, but it has become even more critical as direct, in-person contact is of clinical concern.?A huge challenge for leaders in dealing with Digital Health is to figure out which technological tools to select. They have to decide if a device or application can perform as advertised. It is essential to determine if it will have an impact on the quality of care and outcomes. Affordability is always a concern too. Also, consideration must be given to legacy applications– are they worth keeping and integrating with the new ones? Or should they just be retired? While the first step is to find a reliable and reproducible way to identify Digital Health solutions that work and are of high value, a framework for implementation is essential.

The myriad of stakeholders has distinctive priorities that make all of this difficult to put into practice. We need to move Digital Health hopes systematically from "smoke and mirrors" to impactful reality to create a truly better healthcare experience and system for all. Let’s look at the challenges of the initial selection of technological solutions. Then we will introduce a scorecard for evaluating the technology's quality. Next, a methodology is presented to measure outcomes. Finally, we will offer barriers to implementation, then some suggestions for a strategic framework.

?

The Challenge:

The scarcity of proof makes Healthcare decision-makers reluctant to invest in the resources to evaluate and use new Digital Health technologies. Lim and colleagues did a survey of CEOs from start-ups regarding slow healthcare adopters to digital technology. All agreed that this was due to the asymmetric impact of regulatory pressures; that is, even if a Digital Health product met regulatory requirements, healthcare providers were reluctant to accept risk as there was no evidence to support outcomes. Another reason was the need for multidisciplinary buy-in from other stakeholders.3

Cost issues due to prior investment and ongoing maintenance of existing technological applications likely play a role. Most organizations have not done reliable cost analysis studies. Retiring legacy applications that are not needed or not helpful could lead to substantial overall one-time and annual cost savings even with the added expense of new solutions.

Subjective business decisions made in isolation are often the culprit. The goal of getting to one EMR across many provider groups is one means to improve data accessibility. However, technology leadership is often singularly focused on the directive and may not be vetting the vendor's ability to deliver and support the tool's capabilities, functionality, and need for development. Deadlines are missed, and costs are exceeded. Still, worst of all, the solution may never get to intended production.

Corporate leaders who have the power to grant permission and direct resources see?"the next best thing to come in Digital Health." A tool is quickly given capital support from the company or is acquired. Advocates demand quick implementation of the device. Often, it has no explicit end-user need, has not passed any form of initial vetting, nor has it been shown to improve outcomes in formal pilots.

We see this coming from many other non-clinical divisions. The marketers who have historically been given Digital Health leadership roles love tools to enhance patient experience via the internet. The technology leaders find or create tools that they can solve problems with from their technological perspective. Neither group engages much with clinicians to determine their initiatives' implications on patients, providers, care, and outcomes.

So, we do not have an excellent way to evaluate the technology. Validation requires that we study the technology and its potential effects. First, though, a problem is identified as the reason for trying out the technological solution.

Next, the device must meet all of our five ?"Availability Criteria"- be technologically sound- meaning that it works the way it professes to, is easy to use, scalable, customizable, and affordable. Now it can move to the trial or pilot step for testing in a live environment.

Validation:

The Global Score of Mathews and his colleagues shows promise as a standard way to evaluate the findings from a pilot of a specific technology. The authors have completed a thorough review of the current state of validation of Digital Health. They propose end-user requirements approach assessment across the four technological, clinical, usability, and cost domains. Their Digital Health Scorecard incorporates these four criteria, which they aggregate into a composite Global Score. Individual scores can allow sufficient discrimination of particular products, identify needed improvements or gaps, and compare similar Digital Health solutions.4Focusing on a few is imperative as resources are usually scarce.

The Global Scorecard uses a multi-stakeholder approach that purportedly can objectively and rigorously evaluate solutions. It is comparable to methodologies used outside of Healthcare (such as Underwriter's Lab, which develops safety standards and uses pre-market testing, and Consumers' Reports, which relies on post-market evaluation). It appears flexible and dynamic enough to meet the demands of multiple stakeholders. For example, payers want more efficient use of resources, whereas providers wish for increased reimbursement. The current scorecard uses end-user requirements to determine the maximum impact on patients. This approach can be transparent, thorough, and standards-based. It is currently being tested for validity in different studies.

Outcomes:

Measures of outcomes need to be created to determine how well the solution performed, especially regarding performance around specific case use. If Digital Health is supposed to help achieve the Quadruple Aim, we should incorporate these into particular measures. Dr. Don Berwick and his colleagues introduced the Triple Aim to improve the patient's care experience and populations' health and reduce costs to improve the US Healthcare System.5 This evolved into the Quadruple Aim, as the importance of caring for the provider was acknowledged.6 Many health care organizations have adopted the four aims as their overarching goals. There has never been an impetus to rank them. However, without patients, the health care system would have no reason to exist. Even if quality and patient satisfaction are outstanding, cost-prohibitive care and a lack of clinicians or staff due to low engagement will lead to a model that could not be sustained. The prevailing priority is to improve the patient and clinician experience, hopefully leading to better clinical quality and cost control.

Concerning patient satisfaction, data comes from surveys. Overall, questions are not specific enough, so we need more directed ones that tie back to case uses. Patients are now also customers and consumers. They want to interact with the health care system as they see fit, not just by the traditional telephone call and in-person visit, which involves a process that is not easy to use. They want to engage using virtual tools like audiovisual connections, texting and e-mailing. They want to be able to self-schedule. They want to get referrals, tests, results, and prescriptions quickly. Price transparency is essential too. Finding tools that can achieve these wishes is our mandate.

Physician Engagement starts with improving the EMR with fewer clicks, less need for brain power and time, and better workflows. Frustration over the EMR has directly contributed to the burnout of providers and staff who are less caring and less careful, directly impacting the patient experience and clinical care quality. There is less attrition of patients, physicians, and staff when they are satisfied and engaged. Human capital groups agree that it costs nearly $1M to replace a physician throughout the healthcare system. We do not know the effect of turnover on patient satisfaction and quality of care, but both are likely reduced.

Quality in Medicine has always been about clinical criteria- the quality of life, reduced morbidity, and reduced mortality. The Quadruple Aim's focus, however, is on the overall health of the population. Historically, this was under the purview of Public Health and Preventive Medicine but has morphed into its own Population Health discipline. Measures created by government agencies in collaboration with payers, provider groups, and academic institutions are geared towards payment and are only indirect measures of quality of life, morbidity, and mortality.

Cost considerations have evolved over the years, going from dollars adjusted for inflation to Cost-Effectiveness to Return on Investment to Medical Waste calculations. Value-based care, coupled with Evidence-Based Medicine as a core component of decision-making, has gained enormous popularity since it may be a helpful cost control model. The hope is that this approach will significantly impact the estimated 1/3 of all medical costs being spent unnecessarily in the USA.?

For any of the four Quadruple Aim goals, investigators can create specific outcome measures for a pilot. Financial Analysts must choose newer and more innovative ways to factor in non-monetary benefits. For example, engagement leads to better care, less morbidity and mortality, less attrition of patients and providers and staff, more retained and new patients. A surrogate measure might be non-productive patient time for travel, waiting, and going to the pharmacy. Alternatively, for a physician, measure time to chart in the EMR, lost productivity due to missed appointments from no-shows, and face-to-face time with a patient.

?

Letting Go:

Letting go of legacy applications or figuring out how to integrate them with new technology is a challenge. Over the years, the EMR has not come close to meeting clinician and staff expectations. It is not agile nor easily customizable. Often, only one user can get full functionality on a patient chart at any one time, although a workaround has allowed for limited simultaneous access. It can take multiple clicks to complete a repetitive task, like entering an electronic prescription. Most frustrating for all is that the responsiveness from the vendor to technological issues is insufficient. Organizations are partly responsible for this since they have extensive home-grown IT and CAS groups to manage their EMRs for customization and cost-saving. The result forces the clinician to work for the computer rather than the computer working for the clinician.

There are practical concerns about retiring an established EMR. Moving to another may not make things better. The cost of starting over is a primary issue. Another important consideration is that the ends justify the means- going to a single or limited number of EMRs in a region makes sense from data access and sharing perspectives and cost. Doing this without ensuring that the product meets all five Availability Criteria- does the technology do what it professes? Is it easy to use? Customizable? Scalable? Cost reasonable?- makes no sense. Doing an appropriate comparative analysis looking at other EMR products should be done. Considering novel approaches such as a front-end wrapper might be worthwhile. Foundational applications from companies with such expertise are more likely to be readily available and not require the cost and time of development we are experiencing.

Letting go also encompasses the siloed approach to Digital Health that has plagued organizations for years. Modern-day Digital Health began its foray into health care 20 years ago with marketing teams looking at the internet and consumers. These groups continue to champion customer experience and end-to-end service. They work diligently to connect with consumers and patients to receive an outstanding experience similar to other thriving service industries. While they do look at end-user requirements or case uses, these are typically non-clinical. Technology groups do the same from their narrow application perspective. Success for them is in the implementation of a solution and making it work based on technical specifications. Again, consideration of clinical end-user requirements is often an afterthought. Business and financial groups do similar isolated Digital Health work to get data for operational efficiency reasons. Both payers and providers have marketing, technology, business, and finance divisions doing comparable work in parallel silos. Finally, the payers and the clinical groups look at Digital Health in their way. If all of these groups could collaborate and communicate effectively, share tools and data and resources, and agree on end-user requirements or use cases, we would be much further ahead in achieving practical evaluation and implementation of Digital Health tools.

Implementation: Towards a Strategic Plan

Mathews and his colleagues address organizational factors by suggesting that there is no single owner of a Digital Health solution requirement, making it challenging to develop a scorecard that all would embrace. They state that there are no known optimal requirements due to so many new Digital Health applications. It is hard to determine which stakeholder should take ownership of driving the conditions. We propose that the lead be a blended payer-provider one. This dyad could fulfill the role of the primary owner. Cogan et al. suggest that a collaborative effort between a payer and provider for health IT can be successful by sharing tools and tactics leading to technological systems' interoperability, agreeing on clinical goals and quality measures of outcomes, and sharing data from standard quality measurement tools.7A dyad ought to follow these recommendations.

Operationally, Mathews and colleagues feel that it is not practical to vigorously evaluate more than a few Digital Health solutions at a time, which makes a scorecard more justifiable for high-cost conditions or those in peer-reviewed studies for validation purposes. They wonder if the industry should not self-evaluate. But how likely will they take this on as it would be both expensive and time-consuming? Do any of the other stakeholders want this coming from the industry instead of a more objective source?

Mathews et al. correctly propose that what is essential for the future are resources, collaboration, and time to validate the Digital Health Scorecard and needing input from all stakeholders to align financial incentives to outcomes appropriately. They propose that governmental regulatory bodies and provider health systems lead this. However, they point out that nontraditional players may do better, e.g., CVS and Aetna, Amazon-JP Morgan Chase-Berkshire Hathaway. Even so, these entities are missing knowledge and experience from a critical group, the clinicians.

Stotz et al. interviewed a group of "Next-Generation Payer and Providers (NGPPs)" who have payers and clinicians collaborating effectively: Alignment Healthcare, Clover Health, CareMore Health, Iora Health, and Oscar Health. These payers have new payment models that redefine how patients interact with their health plans. Providers or clinicians are on value-based payment models, engaged in upstream clinical monitoring, focused on primary care, and committed to population health. These NGPPs consider technology the critical enabler of their innovative approaches, including predictive analytics, price and outcome transparency, on-demand care via telemedicine, and AI for care decisions. Key learnings from these NGPPs: use technology to enable more person-to-person interaction, either co-develop or buy from the technology company but not both, use real-time data to support decision making, consider Remote Patient Monitoring for home-based care but know that the technology is not currently easy to use and validation is lacking, and give consideration to creating beta-testing clinic sites for pilots.8

Any implementation framework should include the concurrent evaluation of existing and new technological applications for specific case uses. An end-user requirements approach and a combined Global Score, followed by a Quadruple Aim-based outcome analysis, is ideal. The result would be a set of data-driven recommendations for review.

The final decision regarding tool selection should be made more accessible by the process I have described. Who will make this determination? Using these technological tools to solve problems that span Health and Healthcare, the input from multiple stakeholders would be invaluable- Digital Health, Technology, Marketing, Finance, Medical Management, Population Health, Legal, Human Resources, Patient Experience Providers, and Payers. All parties should have been involved from the beginning and through to the end of this collaborative effort. For final ratification, a consensus-supported recommendation would go to the Digital Health business's "executive board" and clinical leaders, CMIO, CMO, and CEO. Evidence-Based Medicine (EBM) is an excellent model to follow, in which the best available research evidence forms the core of medical-decision making. However, EBM is not perfect since we lack good research evidence for the testing and treatment standards of many of the medical problems we face. In part, this is why we have a pyramid from a base of little evidence that uses expert opinion in the form of guidelines up to the peak with meta-analyses.

So, where does this leave us? Recall that Evidence-Based Medicine is not just about the best available research findings. David Sackett reminds us that it must include clinician experience and the patient's input.9This is consistent with Medicine being an art. That collaboration between patient and physician is a crucial component. The process of technological tool evaluation is similar. It is also an art that uses facts based on Digital Health Scorecard results, Quadruple Aim-based measures to assess pilots' outcomes, and the best available experience, getting input from all stakeholders for the best decision.

Evaluation of the technology is about the standards to follow for the innovation and change that will come as part of an overall Digital Health strategy. Other strategic goals directly impact standards and need to encompass organizational and operational leadership and governance, investments, and workforce. There should be a means to approve and conduct pilots across different ecosystems while providing advisory and consultation support. Digital Health leadership would have much input into the sustainability, spread, and scaling of successful innovations. Selecting a method for evaluating Availability Criteria, then the value of a tool through Quadruple Aim-based outcome measures is a vital strategy responsibility. Collaboration with clinical partners to get buy-in to positively affect workflows, time, expenses, and integration, while dealing with unintended consequences, e.g., expectations regarding higher standard of experience with virtual communication. Leadership would have input into payment model design for new care models to improve the patient experience while meeting payer and provider financial expectations. A key role would be formulating a plan to place technological applications for population health interventions into the community. The strategy should look at the social determinants of health to alleviate those detrimental factors to access and clinical outcomes.

There are no excellent established value and impact-based business models for Digital Health. Next-Generation Payers and Providers (NGPP) may be a good starting point since a provider stakeholder is directly involved. These companies were created to deliver a re-imagined service to patients, prioritizing health and outcomes over utilization. The onus is not placed on the consumer or patient. The payer and the provider have direct risks and ultimately share responsibility for the customer and patient's health and care.

As a starting point, any Digital Health strategy should consider short-term goals for consumers and stakeholders. We all want our members and patients to have convenient, safe, effective virtual care. Both payers and providers see the value in better managing chronic conditions, improving medication adherence, and reducing unnecessary emergency department visits and hospital admissions. Focusing on the elderly, the poor, the disadvantaged racial groups, and those social determinants negatively impacting health is obligatory. Directing patients toward timely and appropriate care at the right location can begin today. Finally, we can use Digital Health tools to facilitate looking after the whole person's overall health.10

Drury et al.'s working paper on investing in Digital Health guides how to think about the process. It can help put together the data needed to make a well-informed investment decision through the Digital Health Impact Framework (DHIF Appendix 2 pp 56-59). The DHIF includes a list of crucial questions for each stakeholder to consider:

1. What is the social and political context? Is there the will and finance to pursue a good case through to implementation?

2. What are the options, including possible public-private partnerships?

3. Do the options fit with health, health care, and Digital Health strategies?

4. What are the intended and probable results, and how long will it take to realize them?

5. What are the priority investments planned, their cost, and how do they help achieve the intended and probable results? This stage can make use of modeling tools for assessing cost and benefits over time and should address: (i) How and when will benefits be realized; (ii) Required results of the preferred option that has the highest priority to be achieved; (iii) Estimated costs and benefits for each stakeholder type; (iv) Estimated monetary values of the benefits; (v) Socio-economic returns for each option and their adjustments for sensitivity, optimism bias, and risk exposure; (vi) How risks will be mitigated; (vii) How and where services will be delivered; (viii) Focus of services; and (ix) Life cycles, affordability of options.

6. What are the priority actions within the resources available?

7. How will the results be monitored and evaluated?

In building the investment case, it will be essential to show that:

i. The proposed initiative is needed and fits well with other relevant strategies.

ii. It represents value for money.

iii. It is commercially viable.

iv. The main investors, who may not be the direct beneficiaries, can afford it.

v. It is achievable.

A means to measure, monitor, and improve performance is mandatory. The Digital Health Impact Framework's (DHIF) consistent methodology appraises estimated costs, net benefits, socio-economic returns, and financial affordability over time of individual digital health projects. It enables bespoke appraisals that can be aggregated to help leaders and planners to:

(i) Understand and develop the socio-economic and financial aspects of their digital health strategies, modify them as needed, and (ii) Make informed investment decisions for sustainable digital health programs and projects.

DHIF is a proven methodology used in over 60 evaluations. It starts by setting a timeline that broadly matches an investment's life cycle. Then, researchers can prepare assumptions and estimates of types of users and stakeholders for each year. DHIF should include estimated changes from Digital Health projects, such as healthier citizens and communities and more appropriate health care utilization. These arise from Digital Health's impact on patients, care providers and citizens, health workers, and health care organizations.

Drury et al. also propose that investment is necessary for any implementation to be successful, while leadership is the key. This investment must come with a clear justification by understanding the context and process for such investment decisions. Success also depends on better data management, including integrating and sharing data, agreement on policies and standards, good security, and all stakeholders getting needed resources. They felt that most digital health investment decisions would do well financially concerning affordability and return on investment and generally support the workforce population's overall productivity.11

Conclusion:

"Smoke and mirrors" aptly describes the current state of Digital Health. To make it smart and pervasive, we need a way to validate Digital Health tools. Start with a particular case use or problem needing a technological solution. Next, determine if Availability Criteria are met before deciding to test it out. ?See if a scorecard genuinely helps the case use or end-user requirement by conducting a pilot.?Then collect outcome measures based on the Quadruple Aim. Using an implementation framework within the context of an overall Digital Health strategy led by a payer-physician dyad, a formal set of findings and recommendations can be presented to executive leadership. All are charged with supporting the final decision as a Digital Health program's success depends ultimately on taking timely and appropriate action.

Lo Fu Tan, MD, MS Sr. Medical Director, Digital Health, Mt. West Region, OPTUMCare

Ron Rubin, BA, Director, Digital Health, Mt. West Region, OPTUMCare

September 1, 2021

Content for this white paper is condensed from the principal author's published book chapter:

Lo Fu Tan (March 3rd, 2021). Emerging from Smoke and Mirrors [Online First], IntechOpen, DOI: 10.5772/intechopen.96212. Available from: https://www.intechopen.com/online-first/75315

References

1.??????????Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post-COVID-19 reality? McKinsey and Company, Healthcare Systems and Services May 29, 2020.

2.??????????Liquid State. The Rise of mHealth Apps: a market snapshot. https://liquid-state.com/mhealth-apps-market-snapshots/ (2018).

3.??????????Lim SY, Anderson EG ICCSS'16: Proceedings of the 2016 49th Hawaii International Conference on System Science (HICSS) January 2016 Pages 3328-3337.

4.??????????Mathews SC, McShea MJ, Hanley CL, Ravitz A, Labrique AB, Cohen AB. Digital health: a path to validation. NPJ Digit Med. 2019 May 13;2:38. doi: 10.1038/s41746-019-0111-3.eCollection 2019.

5.??????????Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs 27, no.3(2008):759-769.

6.??????????Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 20144 Nov;12(6):573-576.

7.??????????Cogan S. How payers and providers can align and collaborate, with and without vertical integration. Health IT Answers, Oct 29, 2020.

8.??????????Stotz c, Zweig M.?Next-generation payers and providers: setting a strategy for tech-enabled innovation. The Rock Weekly Rock Health 2020.

9.??????????Sackett DL, Rosenberg WMC, Muir Gray JA, et al. Evidence-based medicine: what it is and what it isn't. BMJ 1996;312:71.

10.????????Four ways that payers and providers can collaborate on virtual health. Modern Healthcare August 5, 2020.

11.????????Drury P, Roth S, Jones T, et al. Guidance for investing in digital health. ADB Sustainable Development Working Paper Series. Asian Development Bank. No. 52 May 2018.

?