Unique challenges to scale in place based care

Note: Thanks for all the feedback and comments from the last post. It’s not always explicit in each post but when discussing innovations in health as outlined in previous posts they should always be evidence based and regulated appropriately (as indicated by the MHRA medical device changes) and co-developed with all stakeholders clinicians, patients, carers, commissioners etc as outlined in this previous post.

This post builds on the previous one "Scaling Health - patients" which gave a positive view of the potential for digital healthcare solutions to scale by going to patients first. The post doesn't touch on place based care, staff and the diverse populations they support which adds layers of complexity but are the reality of the healthcare system. Some of these aspects will be explored here and in also in a following post.

Location, location, location

In place based care solutions which provide functions such as online consultation and communications tools are well placed to scale. These solutions can provide functionality which is similar to consumer technology meaning it can be familiar to most if not all users requiring little additional training. This type of solution can sit alongside existing IT systems but interoperability (or lack of it) can be the limit to scaling. There are variations in the extent to how the individual IT systems in health and care support interoperability across primary, secondary and community care but the level of interoperability is much lower than in consumer technology. This means even the simplest tools such as messaging tools to patients that rely on the most simple links to help clinicians by completing basic details (e.g. phone number) struggle to link into IT systems stymying opportunities to scale.

Online consultation tools can suffer from this interoperability issue, additionally connectivity is variable across place based care providers. Differences in connectivity is more apparent when comparing rural and urban regions but even in urban areas the connectivity of place based providers is often not sufficient to handle the amount of data that would flow through with online consultation tools. In rural regions the problem can be exacerbated as the connectivity can be limited at the organisation and at the patient and carer. This means that video calling tools that could aid the provision of care and facilitate group meetings across providers can be constrained due to limits in stability and speed of the internet connection. Connectivity can act as a substantial limiter on the ability to scale.

Clinical tools locality

From location to location we find big variations in the diversity of the population and their needs, this means the services and pathways in localities can vary. A digital tool to support place based care in one location might not be effective in another due to the service and pathway differences. The population demographic can also have an impact on the use of tools like online consultation.  For example, significant numbers of people over 55 are not online. So online consultation tools may be less attractive to organisations that support populations with significant levels of elderly population. Once you start adding languages and cultural differences to this it can make what could be a scaleable platform solution more difficult to spread. Tools developed to support place based providers with specific tasks relating to populations can struggle to scale due to the differences of the locality.

The utility of solutions such as clinical decision support systems can depend upon the staff expertise, despite appearing to be general platform solutions can struggle to scale. For example, a newly qualified member of the clinical team will have different decision support needs to a more qualified member of the clinical team. But also a newly qualified member of the clinical team who trained in an organisation with a similar population would have different support needs to someone newly qualified who trained with a different population. This means a decision support tool that is useful for a member of the team might be more of a frustration to their colleague due to differences in their expertise. It is important to understand who you are supporting and in what environment, then co-developing the solution with them. There are a number of rare diseases and situations that are so infrequent decision support can provide substantial improvements.

Scaling digital solutions in place based care

The best placed tools to scale in place based organisations currently are those that support administrative tasks. Most organisations have processes and governance arrangements which require administrative time. Also clinical teams need to ensure the appropriate administration tasks are complete in relation to care provision. These administrative tasks are generally non-patient facing and don’t impact clinical decision making - digital tools in these areas do not need the level of regulation required for medical devices. However they often have essential information so the quality assurance and standard need to be high. Administrative tasks can be specific to the locality and services, these can vary depending upon the patients that the provider organisation supports. There will again be variation in staff expertise who are already doing the administrative tasks and so the expectation of the tool will also therefore vary. On the staff side digital tools may necessitate a change in the responsibilities of a role this is where co-development is essential to developing a successful tool that alleviates burden yet enabling it to function appropriately for the organisation and staff.

Administrative tools can often still need to interoperate with IT systems so this dependancy continues but they are less dependent upon the stability and speed of the internet connection. Additionally administrative tasks can take significant amounts of staff time. In an environment where patients are waiting longer to have an appointment with a member of the clinical team, appointments are too short and workload too high being able to save time by supporting administrative tasks would most likely be welcomed by clinicians, healthcare professionals and provider organisations. Time saved and capacity release can be used to continue to improve the organisation and support colleagues. Where solutions align with administration tasks associated with payments, regulation and other nation wide system structures  they are well best placed to scale across greater geographies with fewer dependancies.

Spreading solutions through inbuilt localisation

In place based care digital solutions have a significant number of dependancies which make it very difficult to create a single solution that can simply scale across geographies and populations. Important details can vary which means that solutions need to be designed to be modular and flexible to be optimised for the needs of each locality. Scale is unlikely to be able to happen in place based care in the way it happens in direct to consumer markets. However, this also means that solutions need to be co-developed making them highly differentiated and tailored for that specific set of users. Providers can then have effective solutions that meet their needs.

Standardised systems and interoperability enables cross functionality so solutions can plug and play enabling scale. But currently systems operate in silos, for solutions to scale across place based care we need the operational systems and processes to be the same everywhere this includes IT, staff, skills, processes, clinical need and education/training. It’s unlikely that local variations will disappear. It’s much more likely that scale means flexible and modular solutions that can be tailored for the needs of each locality.