Digital Health IS Health: How to create an ecosystem so no-one falls through the cracks

Over the past quarter century, general health has evolved into a paradigm of holistic care.

Firstly, we better appreciate how different systems in the body connect with each other – such as the way the gut and microbiome can impact the immune system, which in turn can impact the brain, and so on.

Secondly, we acknowledge that medicine is just one part of health care, not the only part, with doctors no longer at the top of the pyramid. This has driven the shift to multi-disciplinary care, valuing nursing and allied health as equal partners, and respecting complementary health, while also recognising the critical importance of equity and the social determinants of health.

And thirdly, we expect multiple systems to work together. So rather than thinking of hospitals, GPs, aged care, mental health and public health each as islands, we centre the patient, their outcomes and experiences, then build the systems around them.

The upshot of this shift is that digital health is now integral to health. It is one and the same, akin to the evolution of other essential enablers in medicine – pathology, medical imaging and endoscopy. These advances have become fully integrated into the practice of medicine and empower clinicians who can then enhance outcomes for patients.

By treating digital health as a core part of health we are elevating the digital facet, rather than demoting it. But the digital health ecosystem is fragmented, and if we do not glue the bits together, patients will fall through the digital cracks, get lost in the system, and the outcomes and experiences we strive for will not be achieved.

Treatment for the health system must be effective and connected, with all parts working efficiently and in synergy – just like the body, it must remain in homeostasis. If not, cracks will appear that people will fall through, which could reduce the amazing benefits of a connected digital health ecosystem.

These ‘cracks’ are the gaps between digital health applications. For example, a patient may be part of a cutting-edge electronic medical record (EMR) system while in hospital, but once discharged will rely on chance to be picked up by a general practitioner’s practice software.

Across the care continuum, patients move among myriad digital systems. Many clinical incidents result from patients not effectively bridging from one application to another, or users of one system not acknowledging other systems. Often this is because people overestimate how effective their digital system is without appreciating all its limitations.

At Nous we have worked with many Australian health providers on their digital health challenges (see more about our experience below). From this work, we have identified the three steps health services need for their digital health ventures to succeed.

Diagnosis is essential in understanding where the ailments are. In healthcare, we start with a robust history, run tests and scans to understand the problem before rushing to treatment. Digital health is no different. Organisations need to talk to stakeholders to understand the lay of the land, identify where the pieces are and how they connect (or don’t) then discover the pain-points for healthcare staff and patients.

The first step is to map the pieces of your digital health ecosystem to create an ‘anatomical chart’ of your digital and technological footprint, which will vary widely from service to service. Trying to diagnose a person when their anatomy, physiology and chemistry is unknown is like trying to improve your digital health outcomes before charting the terrain.

Given the ubiquity of digital health, your anatomical chart should capture all components of the patient journey – not just the ones currently digitised – so solutions can be applied in the non-digital shadows. Organisations need to undertake an enterprise architecture program, which includes mapping, audit, planning and strategy.

We have developed prioritisation frameworks for multiple organisations around the country. These instruments help you to stay aligned to your strategy and planning, make the prioritisation of initiatives transparent, and keep everyone accountable. They do not need to be complicated, but at least include a simple but objective algorithm to assess impact, risks, costs and implementation effort.

For example, a large national health service recently asked us to map out its entire digital and technological ecosystem – more than 500 applications – as a first step toward improvement. In our experience, many healthcare organisations have not performed this vital stocktake in years.

Departments and services need to do this work before they can understand what is working well, what may be broken, and what needs treatment. Actions need to align with an organisation’s strategy and digital strategy, roadmap, values and vision.

Only then can it explore and benchmark to find opportunities for digital health advancement.

In healthcare, treatment aims to fix something that’s dysfunctional, remove something that’s obsolete and/or to replace something with a new part. We can take the same approach to digital health.

Through an effective enterprise architecture program, organisations can identify what needs fixing, removing and/or replacing. Never rush to install the next shiny thing because it sounds progressive or a senior employee tells you they need it – stick to your plan and build your ecosystem systematically.

If a new application does not align with your strategy, then say no. If a legacy system is three years away from becoming obsolete, don’t bury your head in the sand; start planning and refer back to your anatomical chart. Be sure to robustly assess benefits, risks, costs and how each application remodels the architecture at every step.

Cybersecurity strategy and systems should be important considerations. There should be a focus on data loss prevention given recent threats in healthcare.

Consolidation removes duplication and outdated systems, which will save money. Research robustly to see what is out there and to ensure your process mapping finds you a solution that actually delivers the function and outcomes required. Talk often with your stakeholders – listen to the people who will use the systems daily.

Explore if local and smaller vendors meet requirements and are sustainable. This can enable new ventures to launch and ensures the pipeline of innovation remains strong.

Eventually make a firm decision. This requires close alliance with procurement and financial partners and your colleagues in similar services to allow for benchmarking – do not reinvent the wheel if other services have already solved the problem.

There are some useful tools available.

Recently we have had the pleasure of working with the Digital Health Validitron, led by the Centre for Digital Transformation of Health at the University of Melbourne. The Validitron aims to help the sector design, develop, validate and evaluate new and revised digital applications using a state-of-the-art SimLab and Sandbox. This means the outcomes and experience these products purport to deliver are tested in a research-backed and real-world environment.

Interoperability has been front-of-mind in healthcare for more than a decade but we still have a very long way to go before Australia’s digital health ecosystem provides a seamless patient journey.

The Australian Digital Health Agency is actively pushing for the consistent adoption of digital health standards such as FHIR (Fast Healthcare Interoperability Resources). This will enable all parts of the ecosystem to exchange information consistently, akin to the way a donated heart interacts with the body after a transplant without needing to learn a new way to communicate with the recipient.

Some encouraging advancements include the Health Information Exchange in Victoria (an attempt to connect EMRs across the sector) and the Single Digital Patient Record in NSW (an EMR for all health services across the state).

Consumers of health – all of us – anticipate gradual connection of all these parts so the complex organism that is digital health can work effectively and stop more cracks from emerging.

Throughout the process, organisations must focus on the connected digital patient journey. Some systems are better at connecting the patient journey and staff workflows than others, so this must be a key criterion in your procurement and planning. Indeed, a key factor for decisions along your digital health journey must be an improved patient journey, outcomes and experiences.

Pleasingly, the Australian Department of Health and Aged Care’s recent The Digital Health Blueprint and Action Plan 2023–2033 focuses on the connected patient journey. This document – along with several state-based blueprints and roadmaps – provide excellent guidance on shaping your organisation’s strategy.

But how do we know if improved systems are achieving the intended outcomes? In healthcare, it is bad medicine to provide treatment but not monitor the patient nor understand if your interventions made a difference. So too in digital health, we must first decide what outcomes we have in mind then design a framework for achieving and measuring.

It is necessary to create an outcomes framework (sometimes called a benefits realisation framework). In our experience, when it comes to digital health, these documents do not always exist and when they do, they commonly make good paperweights.

But they need not be overly complicated. They just need to answer some key questions:

• What needs do you want to address? This requires a simple program logic (or theory of action) to clarify your local context.
• What investments are required? This identifies necessary inputs.
• What will we do? This identifies the activities undertaken.
• What will we produce? This identifies the expected outputs.
• What are out outcomes and goals? This identifies the desired change (short, medium and long-term).

In the digital health context, outcomes should focus on clinical and health outcomes for the patient (including patient-reported outcome and experience measures) to ensure the patients are not forgotten. Output measures – such as increased efficiency, shorter waiting times and cost savings (with a focus on return on investment) – are also crucial but should not overshadow patient outcomes.

As in good patient care, leaders should not wait for formal measures before they realise an application is not working – systems should be easy to monitor routinely and this data should represent lead indicators, not just lag indicators. Effective leaders will also be immune to the sunk-cost fallacy and take bold action when systems are not working as intended.

If we fail to take a strategic and structured approach to digital health, the new health ecosystem will remain disjointed and patients will fall through the cracks, have a poor experience or face poor health outcomes. If we fail to act, healthcare’s most precious commodity – our staff – will lose joy in work and our community will suffer.

Digital health IS health. Now is a watershed moment where digital health leaders can design the digital patient journey of the future – one that will connect all the pieces, enable services to integrate and systems to communicate, and place outcomes at the centre.

This way, the whole of digital health will be greater than the sum of its parts and our collective health can improve as technology evolves. This is the challenge that awaits us.

Get in touch to explore how we can help you to develop your digital health solutions.

Connect with Dr Paul Eleftheriou, Kaushal Vyas and Raj Verma on LinkedIn.

Prepared with input from Monique Jackson, Ray Messom and Shreshta Sheri.