Authors : Taylor Johansen (Canada), Emil Ackerman (Finland), Morenike Abidakun (Nigeria), Kushal Kadakia (United Kingdom), Alison Curfman (United States). Reviewed by Laura Lahuerta Valls and Omar Rodríguez Forner (YEL Alumni, Spain)
INTRODUCTION
Digital technologies are being implemented rapidly in healthcare systems around the world, offering potential benefits to streamline care coordination and improve population health. The World Health Assembly Resolution on Digital Health has recognised the value of digital technologies in advancing health aims of its Sustainable Development Goals (WHO, 2021). For example, in the United States, the use of telehealth has grown by 3800% since the beginning of the Covid-19 pandemic (Bestsennyy et al., 2021), which has enabled care continuity despite restrictions on in-person visits to healthcare facilities. However, challenges ranging from adequate coverage to equitable access remain, and must be addressed to avoid unintended consequences. For example, cyber-attacks, data breaches (e.g. the recent ransomware attack on Ireland’s health records (BBC, 2021)), fraud, and abuse (e.g., the rise in false virtual billing claims in the US (Muchmore, 2020)), can all cast a shadow on the successful growth of digital technologies.
Regardless of healthcare system type or geography, similar systemic changes have been observed, from the fourth industrial revolution (Industry 4.0) to increasingly digitally-native generations. Changes in technology availability, consumer habits, environmental needs, and the unrestrained flow of information can all create pressure for healthcare organizations to ride the wave of digitalisation with its attractive promises.
This article offers a simple framework for examining the benefits and drawbacks of digital and technology-driven transformations in healthcare. Selected benefits and drawbacks are discussed within the context of the framework.
THE SOFT FRAMEWORK
Digital transformations will continue to cascade through industries, including healthcare. Each change can itself give rise to a chain of events that can impact user experience, professional scope of practice, accessibility, and so on. With so many potential knock-on effects, which are not always positive, it is useful to organize one’s thoughts when contemplating digital transformation. This article presents the SOFT framework, which we have developed; a tool for operational managers to use in their leadership practice. S.O.F.T stands for Social, Operational, Financial, and Technical – each, an axis of perspective.
The Social dimension refers to the human factors that should be considered. How will the patient experience change? What will clinicians/employees feel about transformation? Will introducing technological advancement help or hinder human communication and trust? One of healthcare’s fundamental tenets is the establishment of therapeutic relationships between patients and their providers; these nuanced social dynamics must be considered in relation to digitalisation. The Operational dimension refers to the mechanics of the healthcare business. Will key performance indicators change? Where does digital transformation sit in relation to corporate strategy? In tandem with considering operational logistics, Financial implications must be evaluated. What kind of investment is required? How will short and long-term resource utilization be affected? Finally, Technical scenarios should be played forward. Does the digital transformation compromise data security? Will it cause a digital health equity divide?
It is recommended that these four dimensions be considered prior to, during, and upon reflection of any digital or technology-driven transformation in a healthcare setting. The utility of this framework can be compared to the well-known SWOT business analysis framework. While it does not claim to be a comprehensive or scientific process, the development of the SOFT framework represents a collaboration of views from global healthcare leaders and can support brainstorming and decision making by health administrators worldwide.
Social Dimension
Geographic disparities to accessing care exist all over the world, and in both rural and urban settings. One benefit of digitalisation is the potential to implement technology that allows for virtual visits. This can alleviate some geographic disparities by expanding the reach of general and specialty care into communities that would otherwise not have access at all. The introduction of telehealth must ensure that additional barriers to accessing digital care – such as interpretation services, access to devices and broadband internet, and digital literacy – are considered to ensure that disparities in access to care are not exacerbated.
One of the greatest barriers to the uptake of digital transformations in healthcare is resistance to change by healthcare workers and patients, alike. While evolution is a constant in operational healthcare settings, willingness to adapt to new ways of carrying out processes or providing service is often a challenge amongst healthcare teams. Adoption of new technologies is a social and behavioural process; its speed depends on individuals, as well as team leadership, and overall culture of the organization.
Difficulty in change management can be related to feelings of insecurity amongst health professionals who lack tech savviness, and equally among patients who are less confident with digital advances. This may be individual-related or simply a feature of the specific technology itself. A recent European study conducted on the use of digital technology in healthcare reported that 28.9% of Europeans lack basic digital skills, which significantly increases the risk of digital exclusion in the context of the rapid digitalisation of healthcare (Taylor et al, 2020).
Patient preference for traditional face-to-face doctor-patient relationships can also serve as a hindrance to the uptake of digital transformation. Some believe that the advent of digital technology is eroding the doctor-patient relationship and distancing patients from their clinicians. Despite the array of advantages offered by Artificial Intelligence (AI) in healthcare, its current lack of human compassion is a major weakness, which limits its applications in a healthcare setting.
Operational Dimension
When access to specialty care is limited and time is of the essence, particularly in rural communities in the emergency department setting, remote consultation can provide significant improvement of timely intervention (Curfman & Marcin, 2018). For example, remote consultation of acute stroke management has led to improved times administering life-saving medications and improved outcomes (Blech & Demaerschalk, 2021). Digitally-driven population health management initiatives, such as remote patient monitoring and even school-based telehealth programs for children can also provide better, more continual care. Quality impacting initiatives such as these constitute operational considerations of digital transformation. It is important to recognize that virtual care is optimal in a continuity setting – that is, utilized as one delivery mechanism within a greater overall continuous plan of care. Fragmented care, regardless of mode of delivery, reduces quality. Therefore, to realize its benefits, telehealth should be integrated into a medical home model (AHRQ, 2021) or similar strategy.
While successful digital transformation can dramatically improve quality of care for the patient, digital innovation can also serve as a source of burnout for healthcare professionals. According to a study by the American Medical Association in the United States, medical doctors have cited electronic health records as a major source of burnout (Collier, 2017). Healthcare roles with tasks that are repetitive, time-consuming, and heavy on data processing (for example, laboratory processing), can benefit from digitalisation. However, some digital processes have been developed with little or no input from relevant health professionals, thus serving as a source of errors and hence adversely affecting both employee satisfaction and quality of care (OECD, 2019). Moreover, the automation of medical care in the absence of good engagement can cause confusion related to scope of practice. Clinicians traditionally have rigid role descriptions and often work in a unionized environment wherein modification to scope of practice is a lengthy process. These logistics can be drawbacks within the operational dimension of digitalisation.
Financial Dimension
Improved coordination of care using digital tools, such as messaging and regular video visits, gives opportunities to improve coordination of care, which can lead to increased medication compliance and improved patient education. Remote patient monitoring programs can also provide more robust data about patient needs and outcomes, allowing clinicians to proactively monitor a number of physiologic parameters in specific disease states (Iqbal et al., 2021). Examples include monitoring pulse oximetry data in patients with Chronic Obstructive Pulmonary Disease, observing daily weights for patients with congestive heart failure, or blood sugar monitoring in patients with diabetes. This kind of proactive, upstream monitoring (light-touch intervention, which is conventionally inexpensive) can prevent downstream interaction with the healthcare system (which is generally for acute healthcare issues and requires more resource-intensive, costly, service). Specifically, digital tools used to communicate with patients can reduce unnecessary expensive emergency department visits and hospitalizations by improving coordination of care and by directing to the most appropriate level of care. Inter-facility telehealth consults can also decrease unnecessary transfers between hospitals if problems can be managed remotely. The potential for cost savings as a result of digital transformation is an important benefit within the financial dimension.
The financial drawbacks to digital transformation in healthcare are most often associated with the inception of new technological systems. The initial investment required to adopt digital technology platforms may be capital intensive for health providers, making it difficult to initiate these solutions (Odendaal et al, 2020). The ability to adopt new technologies also needs to permeate across the whole health system in order to ensure that digital care can be captured as a payable service. For example, publicly funded systems need to develop pay codes for virtual care so that providers can bill for digitally-rendered visits. In other systems, the ability for patients to pay for services needs to be considered in order to obtain an efficient pricing system that is acceptable for payers and accessible to patients (Odendaal et al, 2020). Further, in areas where subsidies to adopt new technologies are required but not available, there can be a spiral of uncontrollable cost.
Technical Dimension
Digital transformation has taken place in many if not most other industries. Patients as consumers of healthcare are used to a certain level of consumer experience in other aspects of their life (e.g. retail), and are starting to demand the same of the healthcare system. Indeed, the Covid-19 pandemic has even accelerated consumer demand for a new kind of healthcare; healthcare providers have been pushed to re-examine service delivery options (Ahmadvand et al, 2018). This phenomenon has given rise to several benefits that can be described within the technical dimension. Technology that enables patients to access their own personal health information (e.g. patient-facing health record portals) allows people to have a better understanding of their own health data, and provides the opportunity for greater education, health coaching, and disease management (Wass et al., 2019). Similarly, wearable devices (whether hospital-grade or commercial), have become increasingly user-friendly and have promoted healthier lifestyles among individuals who may not have otherwise taken note of their own health habits.
Technical drawbacks within digital transformations in healthcare are sometimes underestimated by enthusiastic, visionary leaders – the technical nuts and bolts sometimes left to a small proportion of behind-the-scenes experts (such as IT departments or implementation consultants). However, it is important for leaders to take the time to consider potential technical difficulties in order to manage risk. Roll-outs of digital health solutions need to be monitored as new data being generated must be adequately safeguarded – if not, it can generate issues of confidentiality and privacy (Mitchell et al, 2019). Within digital solutions, the vehicle of delivery, the user interface, must also be simple and easy to adapt to without overburdening the end user (Odendaal et al, 2020). Community connectivity and environmental infrastructure must also be examined closely; unintended downtime can slow adoption of digital technologies and can kill the drive to innovate.
DISCUSSION
Covid-19 marks an inflection point for the digital transformation of healthcare systems across the world. As highlighted in the analysis above, digital technologies offer potential benefits for substantially improving access and quality while reducing the cost of care. While benefits exist across all axes of the SOFT framework, our analysis suggests they are primarily concentrated in the operational (e.g., access, quality) and financial (e.g., cost) sectors. The potential drawbacks associated with usability, affordability, and effectiveness also manifest across the different SOFT perspectives, with a particular focus on the social (e.g., buy-in and burnout) and technical (e.g., privacy and infrastructure) dimensions.
While these examples are by no means exhaustive, the analytical exercise illustrates how the different perspectives of the SOFT framework — social, operational, financial, and technical — can be used by healthcare managers as reference points to evaluate digital transformations from different interlinked perspectives and perform risk management for their organizations. Because this framework is focused on underlying principles, it is applicable to managers working in organizations with different levels of digital maturity, enabling them to better identify the potential tradeoffs involved when identifying, implementing, and scaling new digital technologies.
Healthcare, long an outlier in the global economy for its reliance on paper records and outdated systems like fax machines, is finally entering the digital age. Yet as Covid-19 has shown us, maximizing the benefits and mitigating the risks of new digital technologies will require leaders to treat digital transformation as a process rather than an endpoint. By using the SOFT approach as a guide, managers will be better equipped to navigate the healthcare industry’s new digital frontier.
Source: International Hospital Federation
