The digital hospital in a box...

corbridge, eHealth
Author: 
Richard Corbridge, CIO Health Service Executive, CEO eHealth Ireland

Do you remember being a kid at Christmas time, toys came wrapped and in boxes and by Christmas evening so many of us had reverted to playing with the boxes that all the new toys had come in! Imagine your parent’s frustrations…

Imagine if the hospital EHR came in a box ready to deploy, would we be ‘playing’ with the box within the first week I wonder? Once upon a time we used to talk about a hospital without boundaries, in some areas that evolved to a liquid hospital, as we move to the next decade a new idea is starting to emerge, a new parallel, the digital hospital in a box.

No this isn’t a chapter in the SIMS game or an elaborate Minecraft playground, this is where clinicians, patients and managers want to be! The mobile experience has continued to evolve at such a pace that the expectation of what we can do with our devices puts eHealth into a new world, a world we want to go. A world that seems like it could be attainable with just a little different type of effort.

Taking control as a patient

Twice in one week I have been shown patient applications on mobile devices that enable patients to take control of their care wherever and whenever they want to.

The digital Haemophilia support capability deployed in Ireland allows a patient to be in complete control of their care and the treatment plan they have, ‘live’ from their very own smartphone. Ordering new treatment to be delivered and allowing the health system to track this treatment brings a level of patient safety never before seen. The solution also takes the theories of ‘just-in-time’ efficiencies and applies them to healthcare. Just like the fast-moving consumer goods industries where ‘just-in-time’ was invented, this has brought remarkable cost savings and the removal of so much waste in the delivery of drugs to the patient.

The second app is a collaboration between a charity, an academic partner, a technology delivery group and the health system. The epilepsy patient application now delivered in Ireland brings a huge change to the delivery of care to people with this long-term condition. Communication with clinicians is important for any patient with any long-term condition, and the impact on patients with epilepsy has been particularly revolutionary. A patient can now record and communicate the frequency, type and severity of a seizure to their clinician who can use the app to securely communicate suggested changes to the drug and treatment regime.

For patients with a genomic sequence they can now see the geneticist’s opinion of their illness enabling the control of illness to be shared and the nature of the ‘expert patient’ to evolve considerably. In a remarkably short period of time, some patients have been able to come off the drugs they have been on for long periods due to near real-time evaluation of efficacy of the drugs regime they are on and the shared ownership of data about their illness.   

The question we are asking ourselves as digital leaders in healthcare is, are we trying to change the way healthcare is considered and delivered or are we ‘simply’ trying to improve it. A supercharged hospital in a box could be the answer we have all been looking for. 

How can a digital hospital in a box be constructed?

On a recent study trip to Barcelona I was lucky enough to meet the team from TicSalut. More than anywhere else I have seen, the Catalonian health system has ‘cracked’ the mobile application and data problem for health, and the way they have done this is by taking the concepts of a mobile engendered Eco-System and making it real in every possible way. Catalonia has built the first box for the hospital to be packaged in! How have they done it?

First and foremost, they have managed to maintain control of the market place by offering a type of accreditation which has significant value to the builders of mobile applications. Their brand is trusted, respected and brings value to patients, by offering a marketplace for accredited apps they have managed to ensure an agility to market without stifling the innovation capability of its growth.

TicSalut have gone a step further than merely a ‘kite mark’ for health apps though. As part of the accreditation process the organisation asks that, with patient consent, the data collected in the app is not only made available to the app supplier but also the healthcare system of Catalonia. A clinician can see the information a patient or carer has and from a clinical point of view decide if the information is a valid addition to the clinical record, accepting it into the EHR of the patient where appropriate. The patient then can see they clinical record and can make use of the information inside the apps they have decided to use themselves. All of this strikes me as a bit like a box with both sides pushed open, truly a system facilitating a new eco-system approach to the delivery of healthcare.   

Innovations like these don’t come overnight, of course. TicSalut have been building towards this for 10 years, ensuring that a new paradigm in innovation and openness of data can be achieved for the patients they serve. The concept of the health and wealth of the ‘nation’ really being at the heart of what they are delivering. The links to innovation through universities and academic fellowships are now well established. The apps are always recommendations and not mandatory, also the patient still chooses the app that they want to use. Prescribing an app can take place but it still always comes back to a patient choice.  

Throughout Catalonia where clinical apps are used they can also be rated and reviewed by clinician and patient, taking from the travel industry and sites like Trip Advisor the clinical solutions deployed via mobile are crowd source reviewed and the results of this adds weight to the kite mark applied to the app.

If we are to apply the successful digital lessons of other business areas then we need to ‘wow’ the customer. Healthcare has a difficulty in defining its customer which makes this goal complex but, in the case of the hospital in a box this becomes easier. We need the patient that is receiving care to want to be part of the journey and the clinician who is delivering the care to understand the benefits of the information they are receiving, the veracity of that information. Maybe the much used three V definition of Big Data (Volume, Veracity and Variety) can find better application in simple clinical information! 

Healthcare as a service

The new concepts of digital allows businesses to become services rather than costly (sometimes wasteful) capital expenditure items. Take for example the work Phillips has done at Schiphol Airport, by applying circular economy principles Schiphol Group and Philips have created a new way of working, a new partnership. Philips now has responsibility for delivering light to the airport, responsibility for the fixtures and fittings and ultimately the recycling of the fittings. By taking this responsibility Philips can offer their most innovative and cost effective lighting solutions as a service to the airport, making a capital free investment for Schiphol in lighting innovation. Now apply this to healthcare, and try to do it without creating perverse incentives.

An EHR service cost model in a public healthcare system, facing the budgetary challenges we all understand, cannot be charged for digital solutions per bed or per patient basis easily. Doing this will instead cause a different consideration; whether to put information into the EHR. Yet, the digital service model can still work. A hospital in a box, a digital solution deployed to the patient first can work in this way, we are seeing this with the consumer driven shift in primary care, Babylon Health, WebDoctor.ie and VideoDoc and others here in Ireland are all facilitating some service model type solutions to the delivery of primary care interaction. The patient becomes the payer for the service in a different way; but in a way that enables innovation to be fostered rather than kept to a decade long cycle of investment.  

Service solutions or the new term ‘platform businesses’ are pivoting throughout the globe and becoming new innovations; Tesla becoming an alternative power company, charging home based batteries overnight on off peak electricity or Uber becoming a way of ordering the delivery of vaccinations direct to the citizen in need, and so many more.

The ability to deliver health as a service to patients seems today to be hooked to the mobile capabilities though and particularly to this idea of the healthcare system in a box. In the space of a single piece of writing then we have managed to move from a hospital in a box to the whole healthcare system!

Digital leaders in every jurisdiction of the globe are trying to consider where in the tipping point they are, “are we here to optimise the health system with digital? Or are we here to enable a transformation?” The “healthcare as a service” concept, facilitated by the healthcare system and being delivered in a digital box can transform the health systems of the world! We know that digital is ready but the human factors along with the business change elements, are the more difficult parts to resolve. That’s why I believe the concept of a healthcare system in a box is useful, it simplifies what we are trying to do. Samsung talks about the unboxing of the mobile phone for different reasons at the moment, but if we can deliver, and then unbox the digital healthcare system then maybe we have a route to achieve the business engagement and change that so many healthcare systems need.

Leveraging patient engagement

The healthcare system in a box provides for our ability to be a multi-channel business, at last the engagement of our hard-to-define customer base can be done comparatively easily as we suddenly have many more digital routes to engage through. Engagement has to be done on the needs of the ‘customer’ rather than the organisation and therefore the idea of multiple channels means we can offer the ability to engage in the same way as so many businesses do who successfully put the customer at the heart of what they do, the box has so many routes into it!

One of the advantages of moving to a concept where the digital hospital is delivered through the proverbial box could well be the ability to lock the hospital in a box and use it to protect the data and the experience of the patient. Recent cyber threats and the escalation of the vulnerability of healthcare to cyber attack gives us, the digital health professional, a new challenge to overcome. Placing the digital experience of the patient into their own hands provides healthcare with, at the very least, a new level of vigilance. We don’t ask one person to adhere to hygiene standards to enable infection control best practice to become standard, we ask everyone, maybe that is what can be achieved by ‘crowd sourcing’ the customer in the cyber threat battle. 

We have had the cardboard box since 1817, and now whether it’s Calvin and Hobbes creating a time machine (or a ‘transmogrifier’) or the gag real on the computer game Metal Gear, the cardboard box is an accepted part of growing up; even the national museum of toys in the USA has a box in it, the only non-branded ‘toy’ it has as an exhibition.

So, if the humble cardboard box can become a toy for all our children since the early 1800’s then I am sure as a concept for healthcare it can become the answer to the truly patient focused electronic health record!

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