Digital Health Success
Background and Benefits
There is a groundswell of discussion and activity in the area of digital health. Most life science and healthcare delivery organizations have a published strategy on how they will connect with patients. The COVID-19 pandemic has been a force in driving us from face-to-face contact and some of this activity has been strictly to adapt to the rapidly changing needs.
Even with the stresses of in-patient visits during the pandemic, many organizations have yet to implement a congruent and effective digital strategy. For healthcare providers, it is painful to challenge the status quo and most hospital systems have returned to the traditional ways of delivery. This will have a detrimental and lasting negative effect on their ability to attract quality admissions and remain profitable. As innovators like Amazon and others blaze a new trail, those resistant to change for the sake of quality will find themselves losing the race.
For pharma and medical device companies, lacking a digital plan that augments utilization will equally be damaging. These effects will occur over time but having a plan for measured success is simple. We hope to provide insights into incremental efforts with outpatient services that show an effective path forward.
Our organization played a primary role in one the largest digital health rehabilitation projects in the United States. This well published cardiac rehabilitationservice has served over 16,000 patients at the time of this paper. As with many great successes, it began with adiminutive but highly successful pilot. To prove efficacy, a group of only 37 patients were taken through an 8-week program. The results were extremely positive with all but 37 patients graduating. Our hospital system partner was quite forward thinking on the human benefit to this program that would triple access to this life saving service. They were eager to move forward.
Setting the Stage
Cardiac Rehabilitation is a widely studied service with proven evidence-based outcomes. It has a strong demonstration of reduction in emergency room visits (Lear, et. al., 2014) and mortality (American Heart Association, 2017). We needed to build a business case on the reduction in utilization. For any U.S. based ACO or vertically integrated system, this can be substantial. Using data from a number of long-term studies and Cochrane reviews, we modeled the savings in utilization reduction. We also found that virtual rehabilitation was substantially less costly than in person traditional methodology. Between the two large items (utilization and direct cost), the numbers were profound. We received approval from 13 medical centers and the executive team to move forward.
In any system, even where doctors are employed, the choice of referral is that of the physician. We realized that to be successful, we needed to ensure our 300-potential referring cardiologists were bought into the benefits. This involved a custom communication plan at each of the sites where we identified a champion that was supported by the chief of service. In addition to being patient centered, the program could not increase the administrative or clinical burden to our already busy cardiologists. Taking this into account, we modeled the workflow for referral to be “As Easy as Ordering a BetaBlocker”. Our case managers were also trained in behavioral interview techniques and given tools to communicate success with their physicians. By the time our program reached two years of age, we had 279 of 305 potential cardiologists ordering the service.
Our approach was a
rolling site by site launch. We created a repeatable model of hiring staff, training them and providing the resources they needed to be successful. Working with physician leadership, nursing, dietary and other groups, we authored a comprehensive operation manual covering patient intake, management, discharge, etc. Having a single version of the truth that we could point to eliminated much of the potential site variation in the program. Over an 8-month period, we successfully launched all 13 sites.
Measuring and Communicating Success
Initial measures were limited to operational metrics. We were converting over 90% of referrals into intakes. Access to cardiac rehabilitation tripled over a 30-month period. Leadership updates were provided on a periodic basis with monthly emails at a minimum. Post discharge interviews were conducted with select patients and their stories were documenting. Our client’s public relations team did phenomenal external facing work. An example can be found at
The team’s strategy in the end was quite simple. The program has proven medical benefits. We anticipated outcomes and built a means to deliver the message of success both internally and externally. The program is unsurpassed in the number of lives saved. Our key to this success was multifactorial, however, our unique approach to engagement proved to be most critical.
Managing Digital Health Change
As organizations consider advancing digital health initiatives, there are several factors to consider.
First many strategies tend to be too broad. Our business is managing change and it comes best in incremental and manageable steps. It is sometimes difficult but avoiding the urge to expand your strategy to be more relevant comes with great risk. We promote a clear vision that articulates the goals of your program as an umbrella statement. Beneath that overarching objective should be the categories and individual programs you wish to enact.
Each program should stand on its own merits. There should be a compelling clinical and business reason for the investment. For medical device and pharmaceutical companies, special attention should be paid to align with delivery organizations and providers. Doctors and nurses are the key to quality healthcare and should be a part of your programs. They can also advise on the appropriateness of your solution and how it will impact patient outcomes. There are no shortcuts to improved product performance. Measuring clinical benefits as defined by the medical experts should be the goal.
Select Your Partners Carefully
We have found that the partners you choose is one of the key decisions that you will make. For healthcare delivery organizations, picking a technology or solution partner that shares your values on patient outcomes will pay dividends. If your partner is strictly profit motivated, they are less likely to remain committed to the project over the long term. Both sides of the partnership should have leadership that has affirmed their commitment to the goals of the project.
Make your partners part of all facets of the planning process. There should be no divisions between technology, process and people. Both organizations should provide insight and guidance in all matters. As you make your risk management plans, the value of this will become apparent when redundancy and diversity of thought is introduced.
Select partners with a patient centric mindset. Superior science and medicine that is deftly applied clinically will win the day. If you are working on something exciting that you really care about, you do not need to be pushed. The vision pulls you.– Steve Jobs
Improving Healthcare Access
During our experience in Cardiac Rehab, we saw a 22% increase in black patient participation. Performance as measured by number of sessions was not statistically significant across all races. Our insight is that a well-designed approach that eliminates economic, social and functional barriers to care will better level the playing field. Digital health is unique in that it allows us to reduce costs and improve product/service utilization while increasing access to all.
Some advocate that digital based programs lack efficacy as compared to in person services. We understand that advocating for the status quo may seem safe but often comes with reduced access. The data in this area is unequivocally supportive of digital methods. In Cardiac Rehab there are multiple peer reviewed studies in the most prestigious journals that demonstrate equity (Delal et. al., 2021)
Start Small and Build on Success
Fans of baseball understand the concept of "small ball". This is a strategy that builds off of singles rather than swinging for the fence. This analogy applies well to digital projects. Having a steady cadence of incremental successes will build confidence in your effort and show rapid benefits. On each of our digital health programs,
we have gone from approval to first patient in under 9 months. Using an agile approach that eliminated non value-added components was key.
One of our risk management mitigations was to evaluate each feature for patient benefit and evaluate the impacts if we decided to exclude it. This helped us to travel from drawing board to MVP (Minimum Viable Product) in the shortest period of time. Many projects suffer from over-scope and the desire to create the best product.
Forming a support structure that takes real world input from the project and makes improvements in rapid succession is optimal. Far too much time is wasted on obstacles created by an overzealous approach to features. Keep your feature expectations low and focus on patient safety and quality.
Benefits from Challenging the Status Quo
Avoid trying to “boil the ocean” at all costs. Start small, think big and be prepared to quickly scale the activities that work. Use proven techniques like Human Centered Design, Lean and Design Thinking to define the need and quality for each service. This should lead you to Minimally Viable Product candidates which have clear financial and clinical benefit. To effectively gain buy-in from your hospital and service line leadership, bring data. You may need to pilot the solution to create the data required.
By challenging the status quo of your organization will see the benefits of transformation. Improving results are infectious and cause others to come forward with ideas. Embrace all thoughts, work with teams to define the best solution and don’t let obstacles slow you down.
Change is Hard. We can help.
Resistance to change is part of normal human nature. In medicine, it is especially difficult to propose a modification to the status quo. Oftentimes organizations can view the effort as a foreign virus and key people will be working to eliminate your vision. We bring an evidenced based approach that has a proven record of outcomes. Challenges are identified and risk management plans are instituted. Our Human Centered Design approach engages frontline workers to improve quality and efficiency.
New and innovative approaches to healthcare require diverse and resilient approaches. The complexity of our system can often dissuade great ideas from becoming reality. Experience, tenacity, and an open approach to new ideas lead to success. We wish you well !
Island Creek Partners is a part the of Sandcastle Change, LLC family. We focus on initiating meaningful change for our clients. Organizations that focus on efficiently delivering quality patient outcomes will greatly outperform their peers. This fact is core to our mission. Our experience is in helping organizations transform their culture to align with growth that outpaces their peers.
Steve founded Island Creek Partners in 2017 to serve healthcare and life science organizations. Following a 20-year career at Johnson & Johnson in customer facing roles, he saw an opportunity to provide solutions that delivered better outcomes. Steve has worked with some of the largest global healthcare organizations and leads our practice in that area. We translate our deep understanding ofpatient pathways into better performance for providers, pharmaceuticals and medical device.
Kent is the founder and Chief Transformation officer of Sandcastle Change, LLC. His background in managing successful projects in IT and process reengineering is extensive. The focus of our teams is to enable our clients to better compete and prevail in achieving their objectives. Since founding Sandcastle, Kent has led the development of numerous large endeavors to bring value to those who we serve. He has a passion for understanding the human element in the change process and bringing a thoughtful and compassionate approach to transformation.
American Heart Association. (2017,May). Cardiac Rehabilitation Putting More Patients on the Road to Recovery,from https://www.heart.org/-/media/Files/About-Us/Policy-Research/Fact-Sheets/Clinical-and-Post-Clinical-Care/FACTS-Cardiac-Rehab.pdf
Dalal H M, Doherty P, McDonagh ST, Paul K, Taylor R S. Virtual and in-person cardiacrehabilitation BMJ 2021; 373 :n1270 doi:10.1136/bmj.n1270
Dunlay, S., Pack, Q., Thomas, R.,Killian, J., Roger, V. (2014, February). Participation in Cardiac Rehabilitation, Readmissions, and Death After Acute Myocardial Infarction, American Journal of Medicine. http://dx.doi.org/10.1016/j.amjmed.2014.02.008
Kaiser Permanente. (2020).Bringing healing home with Virtual Cardiac Rehabilitation Program. YouTube. Retrievedfrom https://www.youtube.com/watch?v=qiL3O9b4SJQ.
Lear, S. A., Singer, J.,Banner-Lukaris, D., Horvat, D., Park, J. E., Bates, J., & Ignaszewski, A.(2014). Randomized trial of a virtual cardiac rehabilitation program delivered at a distance via the internet. Circulation: Cardiovascular Quality andOutcomes, 7(6), 952–959. https://doi.org/10.1161/circoutcomes.114.001230
Rubin,R. (2019, August 6). Although cardiac rehab saves lives, few eligiblepatients take part. JAMA. Retrieved fromhttps://jamanetwork.com/journals/jama/article-abstract/2738630
Thomas,E., Lotfaliany, M., Grace, S., Oldenburg, B., Taylor,C.B., Hare, D., ThanujaRangani,W.P., Dheerasinghe, A., Cadilhac, D., O’Neil, A. on behalf of the ADVENT investigators, Effect of cardiac rehabilitation on 24-month all-cause hospital readmissions: A prospective cohort study, European Journal of Cardiovascular Nursing, Volume 18, Issue 3, 1 March 2019, Pages 234–244, https://doi.org/10.1177/1474515118820176