Is COVID-19 enough for the successful improvement of patients’ and citizens’ engagement in e-health?

The Young Executive Leader Initiative of the International Hospital Federation (IHF) is an opportunity for young executives from hospitals around the globe to meet with one another, discuss current trends and challenges, and offer perspectives from their experiences. This year, there are 17 leaders in the program, and the following group will be focused on digital enablement of healthcare and the challenges and opportunities of being a digital leader in a post-COVID world. You can find more information about our program here. This second article questions whether COVID-19 is enough for the successful improvement of patients & citizens’ engagement to e-health. 

Authors: Adroher, C (Spain), Almuntaser, S. (UAE), Bogues, R. (US and UK), Kuhlmann, L. (Germany), Staudt, J. (Germany), Tsai, M. (Taiwan) and Veloso, R (Portugal)

Introduction

The COVID-19 pandemic has added tremendous demands in healthcare and other business sectors. The huge scale of the outbreak and its ambiguity make it challenging for executives to respond. “Indeed, the outbreak has the hallmarks of a “landscape scale” crisis: an unexpected event or sequence of events of enormous scale and overwhelming speed, resulting in a high degree of uncertainty that gives rise to disorientation, a feeling of lost control, and strong emotional disturbance.”1 The SARS outbreak in 2002–03 and now the coronavirus pandemic are examples of such crises.

“Trends before the COVID-19 crisis show some increased interest in applying telehealth services by healthcare providers (HCPs) and patients.”[1] The COVID-19 pandemic facilitated the implementation e-health and promoted the use of digital health tools to engage HCPs and patients to deliver all kinds of medical care.

By using digital solutions, such as mHealth apps and wearables, citizens can actively engage in health promotion and self-management of chronic conditions and provide feedback and data about their health status to health professionals. This engagement and feedback can improve the quality of health services, and ultimately enhance people’s health and well-being. For example, telehealth services are an accessible way for patients to receive care either synchronously or asynchronously. It reduces the burden on patients to take time off work, drive to a location, find parking, wait for the provider, etc. and now help connect patients to care they need with minimal transmission risk of SARS-CoV-2 to and from healthcare providers and patients.

Some examples of digital health initiatives include virtual visits, messaging functionality for patients, portals for patients to check their test results or see past medical history, remote monitoring devices and applications that may or may not be connected to the provider, etc. Digital tools for providers will come in our following article, when we discuss provider engagement. In this article, we will provide suggestions for engaging patients and citizens in digital healthcare tools including the use of the design thinking process, recognising generational differences and the role of patients’ healthcare literacy.

BRIEF OVERVIEW OF THE BENEFITS AND LIMITATIONS OF DIGITAL HEALTH

Is digital health enough on its own or best as a complement to in person care? One of the advantages of telehealth services (as an example of digital health) is that it has facilitated public health strategies during COVID-19 pandemic by increasing social distancing and reducing potential infectious exposures. Digital health tools also reduce cancellations and missed appointments and reduce the need for Personal Protective Equipment (PPE) by HCPs. In addition, remote access to healthcare services support those who are medically or socially vulnerable or in rural and hard to reach communities.[2] A recent systematic review study by Xinchan Jiang published in 2019 that evaluated the cost-effectiveness of digital health interventions (DHIs) on the management of cardiovascular diseases found that DHIs to be cost-effective in all the included studies.[3]

One of the serious limitations of digital health is when an urgent intervention is needed in person due to underlying chronic medical conditions or the need to perform physical assessment. Furthermore, digital health can affect the confidentiality and trust relation between HCP and patient. Due to poverty or low social economy level, limited access to smart devices and connectivity issues are other obstacles for some patients. Patients’ adoption and acceptance of digital health tools can also be a limiting factor.

In 2019, the WHO published recommendations on digital interventions for health systems and urged readers to recognize that digital health interventions are not a replacement for classical functional health systems, it also emphasized that there are significant limitations to what digital health is able to address.  One of the take home messages from this article is that digital health interventions should complement and enhance health system services, but are not substitute the essential components needed by health systems such as the health workforce, financing, leadership and governance, and access to essential medicines.

RECOMMENDATIONS FOR ENGAGING PATIENTS & HCPs

According to A. Hartmann and J. F. Linn[4], focusing on the key elements for improvement enables the identification of common building blocks (‘dimensions’) of success:

  1. Applying leadership, vision and values: encourage political and strategic constituencies to become actively engaged in the process of scaling-up of digital health solutions and enhance the credibility of digital innovations.
  2. Managing stakeholders and ensuring supporting policies: identify the relevant policy issues and supportive policies, such as, laws, regulations, norms or provisions, for each phase of scaling-up.
  3. Developing institutional capacity: develop strategies and policies to empower, educate, and involve patients and citizens in the health innovation process (Further below we share an example of the design thinking process for digital tool development with patients engagement); change the mindset of many healthcare professionals (together with education and co-creation) to help them realize the potential of using digital technology. Invest in HCPs education and better involvement in innovation design; develop strategic plans to guarantee the sustainability of the projects and to provide ongoing competency assessment and personalized support.
  4. Creating incentives and accountability: develop and implement strategies for a funding plan to support the process of scaling-up with success.
  5. Practicing evaluation and monitoring: apply monitoring and ‘evaluation tools’ to examine the extent to which essential elements of an innovation are implemented during scale-up.
  6. Information and Communication Technology (ICT) Infrastructure: consider a set of infrastructures that enables integration of solutions in different existing systems – Identifying usability problems that need to have a thorough assessment; Identifying solutions that use complicated sign-in processes and may have usability challenges; Streamlining the sign-up process with a user-centred design.

 

With this in mind, some possible recommendations include:

  1. Digital solutions must have a relevant impact on their users, and all the main stakeholders should be involved in the process of scaling-up (we highlight this below in our section on generational differences).
  2. Citizens should be able to see who accessed their health data and why. Through this transparency, citizens will be more open to trust data processing and to share their health data.
  3. Creating incentives for managers and staff (e.g., to encourage the implementing agencies to buy into the programs)
  4. Entities must perform assessments of fiscal expenditure and budget of the scaling-up process by analyzing opportunities offered by loans, financing, and grants programs (such as those provided by European programs).
  5. Develop monitoring tools and define Key Performance Indicators (KPIs).
  6. Citizen interactions with different types of healthcare providers and digital tool providers involve the usage of different platforms, and there must be interoperability between the various platforms.

 

Example 1: Portugal

SPMS (Shared Services of the Ministry of Health from Portugal) has been developing several applications for citizens and HCPs, trying to improve the connection between both parties. In this context, the MySNS application, MySNS Carteira (wallet) and PEM (Mobile Medical Electronic Prescription) were developed. In a previous article, we described these programs.

These applications are now widely used by citizens and health professionals in Portugal at a national level. The success of the scaling-up of these applications was due to several good practices. First of all, the precise need for these applications was identified. Second, in order to manage their implementation, the specific problem was analysed as well as its purpose and the targeted audience. Third, the methodology and a value proposition for each solution were developed.

Before the scaling-up process, it was necessary to check if SPMS had the internal skills and human resources to undertake this initiative. Not only was a team of developers needed, but also personnel from other very relevant areas, particularly e.g., a person with strong advocacy skills. As projects are scaled up, the policy framework, such as laws, regulations, and norms, must be supportive if the scaling-up process is to succeed further.)

Example 2. Impact of COVID in the digital health ecosystem in Catalonia

Over the last years telemedicine services have been introduced in the healthcare system of Catalonia. The use of eConsulta, an asynchronous teleconsultation between primary care professionals and citizens has already reached one million cases. Before the COVID-19 pandemic the use of this tool was growing at a monthly rate of 7%, and the growth has been exponential from March 15th until now. The impact of the pandemic on the Catalan digital health ecosystem is huge and the increase of its usage during the last months shows that users are satisfied with the experience. In terms of the content and impact of eConsulta on face-to-face visits, some analysis suggested that there was a broad consensus among GPs that eConsulta has the potential to resolve patient queries, avoiding the need for a face-to-face visit in 88% of cases.

Number of messages and conversations (left axis) and patients and healthcare professional users (right axis)[5]

THE ROLE OF HEALTHCARE LITERACY IN DIGITAL ENVIRONMENT

Health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”[6]

Digital health literacy is “the next extension and uses the same operational definition, but in the context of technology. It involves the delivery (the medium) of the information, as well as the extent to which the information is understood.”[8]

As Dunn and Hazzard point out, technology solutions can both support the improvement of health literacy and be a barrier to health literacy. Digital healthcare tools can increase availability of information including enhanced communication between patient and provider. In addition, these tools have the capability of presenting information that is more specific, engaging and personalized to the patient.[7]

THE ROLE OF GENERATIONAL DIFFERENCES

Generations are clusters of people born in a given period of time, while the definitions of time-frames vary in different study.[8] [9] For example, Pew Research classified generations into:

  • Silent (born 1928-1945, ages 75-92 in 2020)
  • Boomers (born 1946-1964, ages 56-74 in 2020)
  • Generation X (born 1965-1980, ages 40-55 in 2020)
  • Millennials (born 1981-1996, ages 24-39 in 2020); and
  • Generation Z (born after 1997, ages up to 23 in 2020).[9]

 

Although each person in a given generation is unique, people in the same generation share some common generational profiles resulting from various factors, such as major events, economy, and technologies.

Similar to other new technology, the engagement of patients and HCPs to digital health might be affected by various generations. Boomers are the generation experiencing teen culture, social upheaval, and recession.8 They experience the period of time when television emerged and refined from black-and-white to color. As novel information technology, such as internet and mobile devices, were not available during their younger age, this generation might need much efforts to adapt to the current digital health. Growing up in the period with rapid advancement of technology, the generation X is a generation characterized by materialism, technology, and two-parent incomes. The Millennials grew up in the times characterized by downsizing, dot-com startups, diversity, and terrorism. They are connected 24/7 by technology, including the internet. The generation Z grew up in the period of the proliferation of mobile devices. Having internet access at their young age, they spend lots of time on mobile devices and prefer texting and messaging. These generations are quite familiar with the emergence of novel technology, which evolves overtime, it is much easier for them to engage in the emerging digital health.

Although younger generations were easier to engage in novel digital health, the elder generation might currently have more comorbidities and utilize more health-care resources. Therefore, taking into account the need and adaption of elder generation is important in successfully developing novel digital health. Providing options and flexibility for patients to engage with their care in different ways (e.g., telephone call, email, online booking, chat bot, etc.) caters both to individual needs and overarching generational trends. The challenge for healthcare organizations, then, is to offer these options, while integrating them into the workflow of the practice.

Engagement through design thinking – Case study from Vitos Management Group and Vitos Digital Health Ltd, Germany

Development and implementation of e-health-tools for patients in the psychiatric, psychosomatic und psychotherapeutic setting with the aid of the design thinking method

In the psychiatric, psychosomatic and psychotherapeutic field, digital solutions can be a valid supplement (i.e. video chats, apps, electronic patient diaries, online tutorials) within the treatment. In autumn 2020, certified digital applications for patients will be available due to the ‘Digital Care Law’ in Germany. The insurance companies will cover the costs of these digital tools. However, it is necessary to review these digital tools critically in order to convince professionals as well as patients to use them in practice. Within the Vitos group, a corporate group with thirteen hospitals mainly focusing on psychiatry, psychosomatic and psychotherapy, we used the design thinking method to develop ideas for digital tools and to create so-called digital patient journeys. However, we are deeply convinced that these digital tools can only be used successfully as a supplement to the treatment and not as a replacement.

The design thinking method is a very useful method in order to develop patient-centered applications. The patient’s requirements are central to this method. As a first step, the so-called “Personas” need to be developed. The aim is to describe as concrete as possible a patient with all needs, wishes and requirements. As a second step, the corresponding digital patient journey has to be developed. With the aid of 25 colleagues from all Vitos hospitals and of all professions (doctors, psychotherapists, nurses, IT specialists and managers), these two steps have been accomplished during a workshop.

Step 1: Development of personas: “Markus”

Possible questions: What’s the name, age and origin of the person? Is there a diagnosis? How does the person use digital tools? What’s important for him or her? How does he or she feel today? What are his or her goals?

The different groups developed different Personas, in different ages and with different needs. The main goal was to gain a broad overview of patients and their needs during a digital journey. With regard to the age of the Persona, the groups recognized that maybe elderly people do not have the technical equipment or digital understanding as younger patients.

Finally, we looked at another important group: patients with an immigration background and especially migrants whose first language is not the majority language (German). Language discrepancies may result in increased psychological stress and medically significant communication errors [11]. What should we change about our practice or the current options for digital treatment to improve care for persons with severe mental illness and language barriers? The most important aim is to understand language barriers, miscommunication and crosscultural differences that may occur in different healthcare settings between patients and healthcare professionals.[10] We have to find digital services that will best meet their needs.

Below, there is one persona called “Markus” which was developed by one interdisciplinary group.

Step 2: Digital patient journey

Possible questions: How is the person gathering information about his or her medical complaints and where? What are the communication preferences? How can digital tools help to guide the person through his or her individual journey?

Below, the persona “Markus” takes his digital patient journey according to his preferences and actual needs.

The design thinking method helped us to further increase the acceptance of professional staff regarding digital treatment. Furthermore, the participants in the workshop found solutions instead of thinking of potential barriers. These workshops will continue – and in the next step, we will invite professionals as well as patients (whenever possible) in order to integrate the patient´s expertise in the process.

Furthermore, it will be very important to interview family members of people with mental illnesses, who may be the only caregivers. What do they need to cope with their daily challenges? The stress of caregiving has been labeled as caregiver burden in the literature. How to reduce the negative impact of caregiving on caregiver’s mental health and quality-of-life by providing helpful digital tools? What can we learn from family caregivers? Vitos will try to get an approach to these questions by using the design thinking method.

Conclusion

In a recent webinar on digital healthcare, the concept of a ‘Digital Leader’ attracted special attention for our Young Executive Leader team. Indeed, we increasingly recognise that leadership in this matter, as in so many others, is undoubtedly one of the greatest facilitators (or inhibitors) of the necessary change in organisations but, more importantly, in people. Perhaps some have awakened earlier than others, and others have been awakened by the current pandemic situation. Perhaps some of us were more prepared for this fight than others.

But, after all, what is a Digital Leader?  In our opinion, a Digital Leader is, above all, a person who is guided by transparency and collaboration, able to adapt in an agile way to the environment and to the people who evolve in it, and make commitments to internal and external customers. A Digital Leader is constantly looking for value delivery and does so in a humble way. Furthermore, a Digital leader defines the objectives of their projects and assumes effective communication by promoting feedback to unreserved teams. In doing so, a Digital Leader should promote “out of the box” thinking, even when it implies failure, encouraging the autonomy of his teams and their participation in decisions. In the end, a Digital leader is “just” a person whose purpose is, through technology and agile processes, to improve the experience of their people – patients, their community and their fellow employees and caregivers.

We will all agree that the bet on digital healthcare is not restricted to the implementation of new technologies in clinical-administrative processes or the acquisition of often isolated solutions leading to duplication or loss of information. Rather, it requires an effort and a willingness to change: to change the way institutions, professionals, patients and caregivers relate to each other; to an increasingly digital, collaborative and sharing culture. This is why Digital Leaders are needed.

The main question remains: How to improve the digital solutions for citizen-healthcare providers’ interaction and their engagement? While we have focused on patients’ perspectives here, more than anything else, this topic is about international, national and organisational leadership; vision, values, and mindsets; and incentives and accountability. An excellent example of this is the sharp increase in virtual visits during peak outbreaks of COVID-19. This shows that large scale implementation of these tools is possible with the right incentives and urgency.

Although the benefits of the use of such digital solutions/tools are known, we continue to face a number of barriers/challenges such as the lack of interoperability -some digital solutions that are currently in use are not compatible with one another, and they do not support data exchange and sharing. Citizens interact with different types of healthcare providers and a variety of health and care stakeholders, who also use different information platforms (e.g. hospitals, primary care services). We also face challenges with healthcare professionals’ adoption of these technologies and ways of working. Our following article will focus on this matter of adoption.

***

References

[1] Using telehealth services. June 10, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html

[2]  https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html#anchor_1591720077356

[3] X, Ming WK, You JH. The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review. J Med Internet Res. 2019 Jun 17;21(6):e13166. doi: 10.2196/13166. PMID: 31210136; PMCID: PMC6601257.

[4] Hartmann, A., and Linn, J.F. 2020 Focus Brief on the World’s Poor and Hungry People. International Food Policy Research Institute. October 2007. https://idl-bnc-idrc.dspacedirect.org/bitstream/handle/10625/37196/127844.pdf

[5] López Seguí F, Walsh S, Solans O, et al. Teleconsultation Between Patients and Healthcare Professionals in the Catalan Primary Care Service: Descriptive Analysis through Message Annotation in a Retrospective Cross-Sectional Study [published online ahead of print, 2020 Jun 22]. J Med Internet Res. 2020;10.2196/19149. doi:10.2196/19149

[6] R. Parker, S. Ratzan, Health literacy: a second decade of distinction for Americans, J.Health Commun. 15 (2012) 20–33.

[7] Dunn P, Hazzard E. Technology approaches to digital health literacy. Int J Cardiol. 2019;293:294-296.

[8] Wiley S. Understanding today’s workforce: Generational differences and the technologies they use. https://www.firmofthefuture.com/content/understanding-todays-workforce-generational-differences-and-the-technologies-they-use/

[9] Dimock M. Defining generations: Where Millennials end and Generation Z begins. https://www.pewresearch.org/fact-tank/2019/01/17/where-millennials-end-and-generation-z-begins/

[10] Meuter, R.F.I., Gallois, C., Segalowitz,N. S., Ryder, A. G. and Hocking, J. (2015). Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Serv Res (15/2015), p. 371.

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