Implementing digital health requires a change in thinking: the technology must be designed around the needs and aspirations of people who use services; it must be incorporated into how services work, rather than being seen as ‘bolt on’; and it must be flexible so people are able to ‘mix and match’ the different technologies with more traditional approaches, to create a combination that works for each individual.
For this to happen, changes need to be made at three levels:
- At commissioning level, technology must be designed to meet the needs and aspirations of the people who use services and it must be incorporated into the design of care pathways.
- At service level, individual health professionals and teams need training and support to develop the technical skills and confidence and to adapt their practice. Technology-based approaches need to be incorporated into how services work, rather than being seen as ‘bolt on’.
- At patient level, people need to be supported and enabled to use the technology that works best for them, when it works for them, and able to use more traditional methods when those work best them.
The NHS Commissioning Assembly advises that Technology Enabled Care Services should be routinely considered in the design and commissioning of any care pathway. It also has the potential to span patient pathways across different conditions, health care teams, health and social care agencies.
Inside Commissioning magazine, in its supplement on commissioning telehealth, identifies ten key steps commissioners need to take to commission telehealth effectively:
- Communication - identifying leaders and champions throughout the commissioning cycle – from envisaging and consultation stages, to procurement and defining service specifications, training and roll out, delivery and ongoing evaluation.
- Patient and public involvement and engagement for the direction and scope of commissioning of technology enabled care services.
- Considering how telehealth or other digital modalities such as video, telecare (assistive technology), teleconsultations or telediagnostics can be used to drive integrated care and not as standalone solutions.
- Focusing digital delivery of care on hotspots in patient pathways where enhancing self-care or remote care of a patient’s condition with associated interventions can improve the clinical outcomes and/or avoid the use of healthcare services
- Anticipating consequence costs before commissioning digital delivery of care.
- Anticipating the training of health and social care professionals that will be necessary for the effective roll out of digital delivery of care.
- Thinking about what kind of digital delivery of care suits the particular patient population.
- Commissioning evaluation alongside any technology enabled care services, with interim reports that can help to adapt digital delivery of care to different applications or settings.
- Considering what improvement tools should underpin your commissioning and service improvement – leadership, transformational change, service redesign.
- Working closely with all stakeholders.
Whilst digital health has the potential to support the delivery of person-centred care, it there is also the potential to aggregate data to provide wider learning for services. It is therefore helpful to consider at the commissioning stage, how the technology can be utilised to measure and capture meaningful outcomes data, which can provide a continuous feedback loop that informs commissioning and service design.
Read more about these challenges and approaches to addressing them in Tackling telehealth: how CCGs can commission successful telehealth services.
View the NHS Commissioning Assembly’s Technology Enabled Care Services: Resource for Commissioners.
Digital health is often discussed as if the technology is a separate clinical intervention. In fact, it is often simply a different way of undertaking an existing task – such as a patient monitoring their blood pressure at home rather than visiting a clinic, or a patient and health professional having a consultation over Skype rather than sitting in the same room.
If the same task is being undertaken differently – such as a person monitoring their own blood pressure – this could have further impacts on how the service works. The first impact is a greater sense of shared responsibility between the person and the health professionals who work with them, which can start to change the dynamic in their relationship. The second impact is that by taking greater responsibility, people often become more activated in managing their own health. These changes can have an impact on the role of the health professionals. Working with the people who use services and staff is the best way to understand where and how technology can best be incorporated into the care pathway and its impact and implications.
The key is to ensure that these approaches are integrated into the care pathway rather than seen as separate or additional. In some cases the two approaches might be provided in tandem – for example patients might be asked whether they would prefer a follow-up appointment face-to-face or by phone.
Whilst online access and use by the general population has increased dramatically over the past decade, it is by no means yet universal and certain communities may have significantly reduced ability to access or use e-participation methods.
The shift towards ‘digital by default’ and ‘digital first’ means that those who are digitally included can more easily access services, but for other people it may represent a further challenge to accessing and getting the most out of services.
NHS England reports that:
- More than 11 million people in the UK lack basic digital literacy skills.
- More than 7 million people in the UK have never used the internet. Of this 7 million, around 85 per cent are over the age of 55.
- Around 40 per cent of those aged 65 and over do not have access to the internet at home, and 5 million of these have never been online.
- People with a disability are three times more likely to have never used the internet, and 4 million people with a disability have never been online.
The Tinder Foundation, which works in partnership with the NHS to widen digital participation, has reported that there is significant crossover between those groups who are digitally excluded and those who are at risk of poor health. For example, it has found that there is a clear correlation between the socioeconomic status of a ward and both the levels of basic digital skills of its inhabitants and their average life expectancy, with people in deprived areas tending to be more digitally excluded and in worse health.
For some people, infrastructure issues such as lack of access to broadband or poor mobile reception, may also create challenges. These challenges are often in rural areas, where remote access to support would be of great benefit.
A further challenge is that most online content is in the form of text, and similar challenges exist as for other forms of written communication including literacy levels and language comprehension – compounded by the fact many people prefer or find it easier to read from a printed document rather than an electronic screen.
Furthermore, use of technology cannot always replace face-to-face interactions. Some people may feel intimidated by online participation, especially if they feel that they lack digital skills or literacy.
Some approaches to addressing these challenges include:
- Be aware of barriers people experience to using technology enabled approaches and develop approaches to overcome them. Barriers include
- access to technology,
- computer and online literacy, language skills
- physical or mental health issues
- discomfort using technology for some health-related activities
Liaising with local initiatives to support digital inclusion can help. Digital inclusion is a term used for initiatives that help people gain access to online services, support them in using these services, and provide training in digital literacy skills. The local authority is often the lead agency for digital inclusion work and can help you understand how best to support and enable people at risk of exclusion.
Local and national voluntary and community groups may also have guidelines or equipment that can help.
- Consider how you can increase the accessibility and usability of online information and forms. Many websites and online tools include features which help to improve accessibility, including the use of screen-readers for text and captions for videos and the ability to increase text size and change the display colours.
- Recognise that digital technology is not a replacement for other approaches. It should complement traditional methods, and its use should be tailored to the needs and preferences of each individual, recognising that these may change over time.
Quite rightly, NHS commissioners, services and individual health professionals are concerned about governance, security and confidentiality in implementing digital health.
Organisations can (to a greater or lesser extent) control these issues within the systems they use (for example data security for people using tele-monitoring equipment). These systems all need to be developed and implemented with robust security and governance processes.
However, other technologies – most obviously social media, which can be used by anyone with access to the internet, with no training or security protocols – is outside the NHS or indeed any organisation’s sphere of control. Information and comments on social media can and will be shared widely, often beyond the intended audience. Nothing can be assumed to be private or ‘off-the-record’, so people working in services and patients themselves need to be confident the information they are sharing is appropriate before anything is published or posted. Organisations and individuals need to beware of including information in posts which could identify individuals, and to remember that simply removing names is not always enough to protect the identity of patients or members of the public.
When using social media, healthcare professionals and others working for the organisation, must follow their own policies and procedures relating to record-keeping, data security, intellectual property and privacy. It may be helpful for organisations to develop guidelines for safe and acceptable use and publicise these to users.
Leeds City Council, Leeds and York Partnership NHS Foundation Trust, Leeds Community Healthcare NHS Trust, and Leeds Teaching Hospitals NHS Trust have produced social media guidance for all their staff.
There is now a wide range of guidance for health professionals:
- The GMC has produced brief guidance on Doctors' use of social media
- The BMA has produced more extensive guidance on Using social media: practical and ethical guidance for doctors and medical students
- The RCGP has produced a Social Media Highway Code
In some cases, health professionals may be concerned about adopting new technologies into practice.
These concerns can include:
- the impact on their relationships with patients
- changes to their role, including their clinical autonomy and credibility
- adapting how they work, including changing consultations
- how to use the technology
Professional concerns can often be addressed through:
- a clear explanation of the benefits to the patient, including, for example, the ability to undertake more frequent consultations, as well as the fact that this is often an approach patients themselves would prefer
- a clear case for the benefits to the organisation and their practice, for example the ability to offer more appointments
- clear protocols to ensure that the service continues to be provided to people in the way that best meets their needs and preferences (i.e. not a ‘one size fits all, you must…’ approach)
- workforce development, to increase levels of comfort with using the technology and how to adapt their practice
The RCN is developing policy, guidance and resources to support the future needs of nurses and health care workers to prepare them for eHealth in nursing and patient care.