How has COVID-19 changed healthcare professionals’ adoption with digital health tools?

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. In our preceding article, we highlighted some of the benefits of patients using digital tools in healthcare like the ease of access, as well as the challenges like interoperability. We also face a similar set of benefits and challenges with healthcare professionals’ adoption of these technologies and ways of working. In using the term healthcare professionals, we are referring to doctors, nurses, technicians and allied health professionals. We will focus on this adoption in the following article.

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

In our previous article, we focused on digital health initiatives including virtual visits, messaging functionality for patients, portals for patients to check their test results, and remote monitoring devices, among other digital tools. These tools, along with the Electronic Health Record and mobile health record access, are examples of digital technologies that this article will focus on in the context of healthcare professionals’ adoption. Just like we described some of the benefits that digital tools have for patients, these tools can have positive impacts for providers, as well. Digital health tools, such as mobile access to the health record, can streamline healthcare professionals’ daily work flows, can support decision making with real-time access to the relevant data, and can support healthcare professionals understanding of their patients in new and meaningful ways. Digital tools can provide back-up support for physicians as well, such as virtual ICUs (e.g., Cleveland Clinic’s eHospital which provides overnight monitoring support of critical care patients to support the team on the unit[1]). In addition, telemedicine should be an important component of managing the wellbeing and mental health burden of COVID-19 in not only the general population but also healthcare professionals[2],[3].

Ideally, these tools should be designed not only for a safer and higher quality patient experience, but also to ease the tremendous burden and pressure our healthcare professionals face on a daily basis. In 2019, Mayo Clinic published a study which found a correlation between low EHR usability and physician burnout, suggesting improving EHR usability was one factor to reducing physician burnout[4]. This is an excellent example where including clinicians in the design process helps to create usable tools that are beneficial and consistent with their work so as to reduce the burden of documentation and other requirements and better support them in their care for patients.

Implementing information and communication technology (ICT) in healthcare systems requires close collaboration between all healthcare professionals, executives, project managers, and programmers. The engagement of healthcare staff provides precious intellectual inputs about the first-line conditions and needs. These considerations ensure the newly-developed digital health models fit requirements of daily clinical practice. However, healthcare staff usually bring their personal opinions and preferences into the suggestions. Taking these inputs into consideration might hamper the developing process of new digital health models. Therefore, although it is important to engage healthcare staff during the developing process, clarifying the essential parts and focusing on them are imperative in the initial stage of development. After the essential parts of the digital health models have been deployed, fine tuning to meet the individuals’ preferences may make the models even better.

Recommendations for engaging healthcare professionals

Findings from a recent international report published in September 2020 by Deloitte show some initiatives that are crucial to accelerate the digital transformation and therefore, the engagement of the healthcare professionals. Deloitte highlights the following five key areas to keep in mind [5]:

  1. The investment on infrastructure (Wi-Fi, fibre optic, broadband, data storage and consented access to health data and data sharing, 5G technology ,algorithms and smart, devices and support telehealth more effectively, etc.);
  2. Open Electronic Health Records (accessible and integrated);
  3. Increased interoperability (development of shared local or national records with a single patient identifier and transparent consent processes, using agreed interoperability standards, for example, Health Level-7(HL7), Fast Healthcare Interoperability Resources (FHIR);
  4. Effective governance processes (such as establishing the security, safety and ethical use of digital solutions and a code of conduct for data-driven healthcare); and
  5. Leadership (develop digital leadership skills and improve the digital literacy of staff and patients).

We will draw on many of these areas in our experiences below.

EXAMPLE 1: Lessons Learned at Cleveland Clinic

In my experience at Cleveland Clinic and at Cleveland Clinic London, I have observed three important practices that ensure healthcare professionals successfully adopt digital health tools.

Executive investment – Building, implementing, testing and updating digital health tools requires an investment of capital, time and organizational bandwidth. Executives and the organizations they lead must be committed to understanding the benefits of these technologies and the financial investment and processes required to enjoy those benefits. In capital allocation discussions, technology and digital tools should be prioritized making a clear statement of endorsement. This commitment should be communicated across the organization and key metrics should be tracked to understand the organization’s progress. For example, at Cleveland Clinic, our CEO has a transparent scorecard of annual metrics which is shared with 67,000 caregivers. In 2019, one of those metrics was to grow our virtual visits. Commitment, transparency and communication are key to driving culture change and engagement with these new technologies.

A technology ecosystem to support caregivers and patients – Healthcare technology should enable the organization’s mission, vision and values, and is a means to that end. Technologies should serve to enhance and deliver on the mission of the organization, and should be vetted as to whether they support those broader goals and strategies. To that point, no piece of software or hardware should exist in a vacuum which could serve to distract and confuse healthcare professionals; instead, each piece of technology should be assessed for its ability to seamlessly integrate with other technologies and into care pathways. This approach makes adoption easier by enabling healthcare professionals to focus on providing the highest quality of care effectively – the very reason most of us work in healthcare. In turn, this ecosystem of integrated technology also enables and enhances a seamless patient experience that can be self-driven and personalized. In addition, these tools can also help build a seamless integrated network with outsourced vendors and payers, and drive internal operational efficiencies which enhance financial and operational processes.

Clinician leadership – As stated in the second point here, these tools are meant as enablers of safe and high quality care for patients. Clinicians working directly with patients are best placed to lead on these initiatives. At Cleveland Clinic, our physicians champion our digital health and technology initiatives. There are major benefits to this – first, that our physicians can share the direct experiences of what is going well and what needs improvement to inform the design and implementation of new tools and secondly, as our physicians lead these projects and departments, they support adoption through their formal and informal network of peers with other clinicians. One example is Cleveland Clinic’s Center for Clinical Artificial Intelligence, led by Dr. Aziz Nazha, which facilitates collaboration among physicians, researchers, computer scientists and statisticians to advance Artificial Intelligence in healthcare.  The Center provides support for physician researchers to gain expertise in programming and building Machine Learning models, evaluating the results and the data using their clinical knowledge, and then implementing those results and those tools into their clinical practice through partnering with IT and administration.

Since COVID-19, these practices have been further cemented in their importance. Executive investment provided resources and effective communication of resources like virtual visits. Indeed, the pandemic forced professionals around the globe to adopt new technologies as one of the only ways to stay connected with patients. The ecosystem of technologies became critical as we relied on this integration to give updates on Personal Protective Equipment, equipment, facilities and caregivers (employees) in real time. Clinician leadership with experience treating patients in the COVID context and hearing experiences from their colleagues helped guide healthcare staff through a challenging time of uncertainty.

With these three practices in mind, another lens through which to consider digital transformations is change management. Consider the 8 steps from John Kotter, as we live in a world where “business as usual” is change.

[6]

To break some paradigms of our healthcare professionals we need to focus on these actions:

  1. Management based on measurable indicators;
  2. Constant feedback to our teams;
  3. Monitoring our projects on the field;
  4. Auscultation of internal and external customers;
  5. Definition of the Strategy by Top Management;
  6. Involvement of the Local Commission of Clinical Informatization;
  7. Massive training of professionals ;
  8. Provide all the necessary tools;
  9. Simplify clinical and administrative processes;
  10. Share indicators, expected results and implementation objectives
  11. Explore the health gains of these tools

 

We believe that providing  time for our healthcare professionals  for training in digital tools, to bet on more agile clinic-administrative circuits, standardizing the digital platforms of health institutions and continuous training of key-users and the nomination of “ambassadors” of tele-health in each department,  are the key of the success of increase the engagement of our professionals to this digital era.

Example 2: Dubai Experience in engaging healthcare providers to e-health

Since COVID-19 crisis, stakeholders realise the need to engage healthcare providers more with e-health. This is being implemented to minimize healthcare provider-to-patient contact and to reduce spread of infection.

In my workplace in Dubai, we (as healthcare providers) have recently started receiving emails regarding digital health, including surveys on how much knowledge we have about digital health. This was never mentioned before in this setting, as far as I remember. More webinars and virtual seminars have been arranged to introduce digital health and make healthcare providers more familiar and involved with the updates in the region and worldwide regarding e-health.

In 2016, Dubai Health Authority (DHA) held a forum on digital transformation. The forum discussed the importance of healthcare IT transformation, opportunities and challenges in the field and the future vision up to 2021. The forum also discussed how to keep up with new trends in digitisation and eHealth and ways to promote continuous innovation. It was highlighted that DHA’s ongoing projects at that time, including (Salama: an electronic medical record), are particularly vital because they will help providing every patient in Dubai with a single electronic file. In fact, these projects will be integrated with National Unified Medical Record, which will be developed by the Ministry of Health so that health information can be shared not just at the Dubai level but also at a UAE level. These initiatives are aligned with the Dubai smart government strategy to transform Dubai into a smart city.

Just recently, during the COVID-19 era, video call clinic appointments have been initiated in our pediatric neurology outpatient clinic at least once a week. It has been a challenge for us and patients for a long time to accept the concept of time facing patients instead of face-to-face conversation. We never thought that would be appropriate, but nothing is impossible. With Salama (Dubai Health Authority electronic medical record), which was successfully launched in 2017, the video calls are now much easier to implement despite the technical issues, and it is now acknowledged that video calls are also a good way to save time and resources.

Within Dubai Health Strategy 2016-2021, there is a mission to Transforming Dubai into a leading healthcare destination by fostering innovative and integrated care models and by enhancing community engagement. There are some initiatives embraced by Dubai Health Authority to improve Medical Informatics and Technology that include: establish Smart solutions for non-clinical services, establish consumer centric online data platform, and establish Smart solutions for clinical services.

Another initiative related to medical education of healthcare providers during COVID-19 pandemic, is providing free digital information for healthcare professionals in the UAE with collaboration of The Dubai Health Authority (DHA) with international strategic partners like the American Academy of Pediatrics and the New England journal of Medicine. The information includes the latest global developments related to COVID-19 research, medical practices, guidelines and protocols to combat the disease. This initiative comes at a time when healthcare professionals are in need of official and trusted information on COVID-19. DHA’s electronic medical library includes more than 200,000 e-books, 1,600 medical magazines and 19 million medical articles.

EXAMPLE 3: ENGAGING STAFF TO E-HEALTH TOOL USING THE LEAN AGILE LEADERSHIP – PÓVOA DE VARZIM/VILA DO CONDE HOSPITAL CENTER, PORTUGAL

In 2018, when the new Board of Directors took office, we came across a classic functional organisational structure, normal for a hospital. Production oriented, with a vertical hierarchy in decision-making and a clear inefficiency in communication. Nothing very different from the reality of another hospital of the Portuguese National Health Service. The word “project” existed only in the IT service vocabulary. Mainly obstacles; agile, not at all.

Early on, our focus for change was geared towards people. On the one hand, our external client: the patients and their families, and on the other, our internal client: our 800 healthcare professionals. Because we believe in management, we realized that the most agile way to go forward was to deliver value to our internal customer and thus, more easily implement a culture of sharing value for our patients and their family members. At the same time, we have metrics to comply with and certainly did not want to lead our professionals to burnout. To proceed at best, this dynamic had to happen collaboratively, in a spirit of continuous improvement, always with a focus on delivering value.

It was in this way that we started by identifying transformation initiatives versus recurring initiatives that could need improvement.  We then tried to implement Hospital Lean Agile, as a process improvement strategy in which the patients’ perspective on value influences the kind and delivery of health care services. Lean healthcare intends to link all value-adding steps in a seamless value stream. Here are some of the steps which were implemented:

  1. Addressing the recurring initiatives, and starting at the top, we dematerialised the board meetings; we promoted multidisciplinary work meetings in the top and intermediate working groups, and 5 minutes daily meetings between intermediate and base management teams. Walking Meetings is another tool to generate another creative dynamic within the team and, of course, a good way to promote health.
  2. We jointly created the Paperless Office with the participation and involvement of our internal customers, accompanied by the Clean Desk initiative, which was greatly driven by the current pandemic situation.
  3. We developed an app for meal management integrated in the employee portal (this feature was added due to the pandemic and an expressed need of our professionals). The same happened with the app for managing labor hours, whose requirements were raised with our professionals.
  4. Once a week, we publish all the content in an Infomail to promote the osmotic communication of our initiatives and projects.

 

There were small changes that streamlined our routine and made the delivery of value much easier. Here are some other examples:

We created the Citizen Space – to promote health literacy. Its work is focused on connecting the hospital to the patient and, therefore, initiatives such as: Digital Citizen Literacy – we signed protocols with 40 municipal institutions to promote Citizen Digital Literacy outside the hospital; “The Hospital goes to the Beach Project” – during the stay of the citizens on holidays in our local beaches, our staff trained the citizens on e-health tools. In August, more than 2000 citizens adopted our e-health tools.

This entire digital transformation project was built on agile logic, on results-oriented sprints, and respond to the needs of our patients and family members. For example, with COVID-19, we adapted the tool with the project we named “still here” in order to give a proactive response to our patients (availability to medical teleconsultations, for example, and videocalls between inpatients and their families).

Our bet on Hospital Lean Agile is concrete. We know it is a journey and the path is made by walking.  The world needs Agile Leaders, let’s walk together!

EXAMPLE 4: FOSTERING COMMITMENT OF INTERNAL STAFF DURING THE IMPLEMENTATION OF DIGITAL TOOLS WITHIN THE TREATMENT – EXPERIENCES FROM VITOS MANAGEMENT GROUP AND VITOS DIGITAL HEALTH LTD, GERMANY

The healthcare environment is becoming more distributed and complex. The acceptance of professional staff concerning digital tools is therefore a critical success factor when it comes to concrete implementation in practice. In addition, even the group of professional staff (doctors, psychotherapists and nurses) has different opinions about e-health tools for patients. Therefore, it takes different approaches to convince these different sub-groups.

However, there is one point, which is very important to all of the sub-groups: the personal contact to the patient. Professional staff needs to understand why it is important to use digital tools – even to ensure long-term quality improvement and sustainable economic development. To answer this question: in case we as a clinic do not use digital tools – others, like the Big Four (Amazon, Facebook, Google, Apple) or the huge amount of startups will. Patients will maybe use the more innovative treatment and leave the classical treatment structures. Their expectations about healthcare services are increasingly being informed by their experiences with large digital-born companies like apple, google and amazon.

As a second important factor, the professional staff needs to know that these digital tools will not supplement the personal contact to the patient. Within our clinics, we made the experience that the involvement of the affected professional groups is a critical factor. Information, communication, involvement and training are the classical instruments when it comes to change management. Therefore, a strategy is needed which involves all these instruments. Digitalisation allows for more flexibility in the case of remote working activities, e.g. teleworking, video conferences and virtual services performed through online platforms. Usability and daily workflows can be improved by single-sign-on solutions for professional staff.

In the Vitos clinics, we carried out different projects in the field of blended care in order to gain practical experiences. We introduced some applications for patients with depression, anxiety and burnout in different parts of our clinics. Mainly psychotherapists led these projects. These psychotherapists played a very important role as they acted as multipliers in the clinics. This step further increased the acceptance of professionals within the clinic.

To sum up, the following instruments and measures appear to be of critical importance when it comes to the implementation of digital tools:

Information: Why do we need to treat patients with digital tools? Vitos integrated appropriate information into the balanced scorecard, which has a high level of awareness within the organisation [7].

Communication: How does the implementation of digital tools affect the treatment in the clinics? In addition, what does Vitos do? Measurable benefits of using new digital tools should be raised and communicated (for example outcome measures for psychological interventions by using blended care approaches).

Continuous involvement of affected people in the process.

Time: the acceptance process needs time and can´t be done within a few days or months. The change in culture needs time. To build and maintain a learning culture within the organisation will support this process.

Further steps and approaches:

Medical errors and other safety lapses persist even in the strongest healthcare systems and are often caused by inconsistencies in care and lack of adherence to good practices. Digital tools can help to avoid such errors. We should raise awareness for these issues by informing and training professionals.

Designate “digital ambassadors”: For example, professionals could attend in special digital ambassador qualification programs and share their knowledge as multipliers.

Motivational push: We should improve the “fun-factor”: Serious games for example are applicable in various situations and can help to combine training and gaming.

Big data analysis and artificial intelligence: We should use big data analysis and AI to forecast hospital occupancy, risks and trends – based on hospital patient journey data and patients’ characteristics (diagnosis, mean residence time, etc.) as additional model parameters. Vitos will develop such a complex model and try to improve prediction accuracy continuously.

Healthcare Professionals’ Adoption of digital health During COVID-19

The adoption of digital health has been accelerated during the COVID-19 pandemic. In addition to top-down implementation, more and more examples of digital health have come from a bottom-up initiation. The fields adopting digital health have also become much wider than ever before, including quarantine station, outpatient clinic, emergency department, home medical service, regular ward, negative-pressure isolation ward, and so on. For example, in Taiwan, some hospitals developed integrated hospital quarantine systems, including the information of quarantine policy and the visitors’ immigration information downloaded from the government’s cloud system[8]. To minimize the risk of in-hospital spread of COVID-19, Kaohsiung Medical University Hospital (KMUH) developed an active surveillance system to identify inpatients whose pneumonia is not improved with antibiotics and asked the healthcare professionals to evaluate the need of examination for SARS-CoV-2[9]. As critical supply shortage of personal protective equipment (PPE) occurred in many parts of the world, Tsai et al. demonstrated the usefulness of some digital health strategies, namely electronic PPE (ePPE), to reduce the use of PPE while caring for patients of COVID-19 [10].

The COVID-19 pandemic has accelerated this entire digital transition and rethinks the way we relate to work and people, but probably there was no time enough to align strategies, consolidate the adoption of these digital tools by professionals and to boost digital literacy and citizens’ health. We must therefore insist on continuing to invest in this path and to do so in a coherent and planned way.

For those who live the dream of being able to contribute to the improvement of the experience of patients and professionals through innovation, having the opportunity to share the best practices in this article is a huge privilege.

The sense of urgency caused by the pandemic has had a catalyst effect of change in health organisations, and the speed with which some changes have occurred, makes us believe that it is possible to make what has before seemed ‘impossible’.

Conclusion

In our discussion, we have found three critical success factors in the adoption of technology by healthcare professionals:

  1. Strong collaborative work among the various services of an hospital (Installation and Equipment Service, Information Systems Services, Communication, Security, among others);
  2. Involvement of frontline professionals in the search and proposal of digital solutions; and
  3. The importance of observing, discussing and acting on the ground using technology and artificial intelligence. Agile development means testing tools with end users and iterating often with real-time results.

 

In particular, the awareness of health professionals about the role of digital, was accelerated under COVID-19 by the need to solve the following problems, among others:

  1. Preparation of the restart of regular care activity, in which it was necessary to think of non-COVID circuits, admission flows in the hospital, screenings, COVID tests;
  2. Challenge of agendas and queues inside of the hospitals; and
  3. Dematerialization as something inevitable and increasingly inferred.

 

Looking to the future and reinforcing the positive changes from COVID-19, we need to reinforce a set of lessons and some opportunities that we should not waste including the following:

  1. The drive and encouragement of smart health and web culture, in particular the dissemination and generalization of teleconsultation and videoconferencing;
  2. Technology will have advanced more in the first three or four weeks of confinement than in the last ten years; and
  3. The advantages of taking Health as a strategic priority at national and global level and, consequently, as an important driver of economic recovery through this digital transition.

 

More than ever before, it is necessary to act decisively in Industrialization, Innovation, Data and Digitization of Health and for these challenges we need to improve the engagement of our healthcare professionals and support them, lead them by example and give them continuous feedback and outcomes of the digitals initiatives, showing them the tremendous gains of using these digital tools.

***

References

[1] Cleveland Clinic Nursing Operations. “EHospital Program Enhances Care in Medical ICUs.” Consult QD. Cleveland Clinic, December 11, 2015. https://consultqd.clevelandclinic.org/ehospital-program-enhances-care-medical-icus/.

[2] Moazzami, Bobak, Niloofar Razavi-Khorasani, Arash Dooghaie Moghadam, Ermia Farokhi, and Nima Rezaei. “COVID-19 and Telemedicine: Immediate Action Required for Maintaining Healthcare Providers Well-Being.” Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology. Elsevier B.V., April 4, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7129277/.

[3] Zhou, Xiaoyun, Centaine L Snoswell, Louise E Harding, Matthew Bambling, Sisira Edirippulige, Xuejun Bai, and Anthony C Smith. “The Role of Telehealth in Reducing the Mental Health Burden from COVID-19.” Telemedicine journal and e-health : the official journal of the American Telemedicine Association. Telemedicine Journal and e-health, March 23, 2020. https://pubmed.ncbi.nlm.nih.gov/32202977/.

[4] Melnick, Edward R, Liselotte N Dyrbye, Christine A Sinsky, Laurence Nedelec, Michael A Tutty, and Tait Shanafelt. “The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians.” Mayo Clinic Proceedings, November 14, 2019. https://www.mayoclinicproceedings.org/article/S0025-6196(19)30836-5/fulltext.

[5] Taylor, Karen, Bill Hall, and Sara Siegel. “Digital Transformation: Shaping the Future of European Healthcare.” Deloitte Centre for Health Solutions, September 2020. https://www2.deloitte.com/content/dam/Deloitte/pt/Documents/life-sciences-health-care/Shaping%20the%20future%20of%20European%20healthcare.pdf

[6]“​Kotter’s 8-Step Change Model.” Edinburgh Napier University. Accessed October 27, 2020. https://staff.napier.ac.uk/services/hr/workingattheUniversity/LandD/organisational-change/support/building-your-resilience/Pages/Kotter’s-8-Step-Change-Model.aspx.

[7] Kaplan, Robert S., and David P. Norton. “The Balanced Scorecard-Measures That Drive Performance.” Harvard Business Review. Harvard, 1992. https://hbr.org/1992/01/the-balanced-scorecard-measures-that-drive-performance-2.

[8] Juang, Shian-Fei, Hsiu-Chu Chiang, Ming-Ju Tsai, and Ming-Kuo Huang. “Integrated Hospital Quarantine System against COVID‐19.” The Kaohsiung Journal of Medical Sciences 36, no. 5 (April 13, 2020). https://doi.org/https://doi.org/10.1002/kjm2.12216.

[9] Lin, C-Y, C-H Cheng, P-L Lu, C-T Hung, H-H Lo, M-J Tsai, and J-Y Hung. “Active Surveillance for Suspected COVID-19 Cases in Inpatients with Information Technology.” Journal of Hospital Infection 105, no. 2 (March 31, 2020): 197–99. https://doi.org/https://dx.doi.org/10.1016%2Fj.jhin.2020.03.027.

[10] Tsai, Ming-Ju, Wen-Tsung Tsai, Hui-Sheng Pan, Chia-Kuei Hu, An-Ni Chou, Shian-Fei Juang, Ming-Kuo Huang, and Ming-Feng Hou. “Deployment of Information Technology to Facilitate Patient Care in the Isolation Ward during COVID-19 Pandemic.” Journal of American Medical Informatics Association, June 9, 2020. https://doi.org/https://doi.org/10.1093/jamia/ocaa126.

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