**5. Letting go**

Letting go of legacy applications or figuring out how to integrate them with new technology is a challenge. Our leadership contracted with the EMR vendor with minimal clinician input. Over the years, albeit not unlike most EMR applications, it has not come close to meeting our providers' and staff's expectations. It is not agile nor easily customizable. Only one user can get full functionality on a patient chart at any one time, although a workaround has allowed for limited simultaneous access. It takes multiple clicks to complete a repetitive task, like entering an electronic prescription. Most frustrating for all is that the responsiveness from the vendor to technological issues is insufficient. In part, our organization is responsible for this since we decided to have extensive home-grown IT and CAS groups to manage this EMR for customization and cost-saving. The result forces the clinician to work for the computer rather than the computer working for the clinician. Despite these concerns, it has become the go-to EMR in our region. This vendor has also entered into the patient management product lane by introducing its patient platform, a scheduling application, and patient communication solution, including video and texting. This process has been three years in the making, but out-of-the-box baseline functionality is low, and much of their solution requires ongoing development.

There are practical concerns about retiring this EMR. We have used it for nearly two decades, and moving to another may not make things better. The cost of starting over is a primary issue. Another important consideration is that the ends justify the means- going to a single or limited number of EMRs in a region makes sense from data access and sharing perspectives, and cost. Doing this without making sure that the product meets all five Availability Criteria- does the technology do what it professes? Is it easy to use? Customizable? Scalable? Cost reasonable?- makes no sense. An appropriate comparative analysis looking at other EMR products should be done. Considering novel approaches such as a front-end wrapper might be worthwhile. Foundational applications from companies with such expertise are more likely to be readily available and not require the cost and time of development we are experiencing.

Letting go also encompasses the siloed approach to Digital Health that has plagued organizations for years. Modern-day Digital Health began its foray into health care 20 years ago with marketing teams looking at the internet and consumers. These groups continue to champion customer experience and end-to-end service. They work diligently to use technology to connect with consumers and patients to receive an outstanding experience similar to other thriving service industries. While they do look at end-user requirements or case uses, these are typically nonclinical. Technology groups do the same from their narrow application perspective. Success for them is in the implementation of a solution and making it work based on technical specifications. Again, consideration of clinical end-user requirements is often an afterthought. Business and financial groups do similar isolated Digital Health work to get data for operational efficiency reasons. Both payers and providers have marketing, technology, business, and finance divisions doing comparable work in their parallel silos. Finally, the payers and the clinical groups look at Digital Health from their relatively narrow perspectives. If all of these groups could collaborate and communicate effectively, share tools and data and resources, and agree on end-user requirements or use cases, we would be much further ahead in achieving practical evaluation and implementation of Digital Health tools.

## **6. Implementation: towards a strategic plan**

Mathews and his colleagues address organizational factors by suggesting that there is no single owner of a Digital Health solution requirement, making it challenging to come up with a scorecard that all would embrace. They state that there are no known optimal requirements due to so many new Digital Health applications. It is hard to determine which stakeholder should take ownership of driving the requirements. We propose that the lead be a blended payer-provider one. This dyad could fulfill the role of the primary owner. Cogan et al. suggest that a collaborative effort between a payer and provider for health IT can be successful by sharing tools and tactics leading to technological systems' interoperability, agreeing on clinical goals and quality measures of outcomes, and sharing data from standard quality measurement tools [10].

A dyad ought to follow these recommendations.

Operationally, Mathews and colleagues feel that it is not practical to vigorously evaluate more than a few Digital Health solutions at a time, which makes a scorecard more justifiable for high-cost conditions or those in peer-reviewed studies for validation purposes. They wonder if the industry should not self-evaluate. How likely will they take this on as it would be both expensive and time-consuming? Do any of the other stakeholders want this coming from the industry instead of a more objective source?

Mathews et al. correctly propose that what is essential for the future are resources, collaboration, and time to validate the Digital Health Scorecard and needing input from all stakeholders to align financial incentives to outcomes appropriately. They

#### *Emerging from Smoke and Mirrors DOI: http://dx.doi.org/10.5772/intechopen.96212*

propose that governmental regulatory bodies and provider health systems lead this. However, they point out that nontraditional players may do better, e.g., CVS and Aetna, Amazon-JP Morgan Chase-Berkshire Hathaway. Even so, these entities are missing knowledge and experience from a critical group, the clinicians.

Stotz et al. interviewed a group of "Next-Generation Payer and Providers (NGPPs)" who have payers and clinicians collaborating effectively: Alignment Healthcare, Clover Health, CareMore Health, Iora Health, and Oscar Health. These payers have new payment models that redefine how patients interact with their health plans. Providers or clinicians are on value-based payment models, engaged in upstream clinical monitoring, focused on primary care, and committed to population health. These NGPPs consider technology to be the key enabler of their innovative approaches, including predictive analytics, price and outcome transparency, on-demand care via telemedicine, and AI for care decisions. Key learnings from these NGPPs: use technology to enable more person-to-person interaction, either co-develop or buy from the technology company but not both, use real-time data to support decision making, consider Remote Patient Monitoring for home-based care but know that the technology is not currently easy to use and validation is lacking, and give consideration to creating beta-testing clinic sites for pilots [11].

Any implementation framework should include the concurrent evaluation of existing and new technological applications for specific case uses. An end-user requirements approach and a combined Global Score, followed by a Quadruple Aim-based outcome analysis, is ideal. The result would be a set of data-driven recommendations for review.

The final decision regarding tool selection should be made easier by the process I have described. Who will make this determination? As we are using these technological tools to solve problems that span Health and Healthcare, the input from multiple stakeholders would be invaluable- Digital Health, Technology, Marketing, Finance, Medical Management, Population Health, Legal, Human Resources, Patient Experience, Providers and Payers. All parties should have been involved from the beginning and through to the end of this collaborative effort. A consensus supported recommendation would go to an "executive board" made up of the Digital Health business and clinical leaders, CMIO, CMO, and CEO for final ratification. Evidence-Based Medicine (EBM) is an excellent model to follow, in which the best available research evidence forms the core of medical-decision making. However, EBM is not perfect since we lack good research evidence for the testing and treatment standards of many of the medical problems we face. In part, this is why we have a pyramid from a base of little evidence that uses expert opinion in the form of guidelines up to the peak with meta-analyses.

So, where does this leave us? Recall that Evidence-Based Medicine is not just about the best available research findings. David Sackett reminds us that it must include the addition of clinician experience and the patient's input [12]. This is consistent with Medicine being an art. That collaboration between patient and physician is a crucial component. The process of technological tool evaluation is similar. It is also an art that uses facts based on Digital Health Scorecard results, Quadruple Aim-based measures to assess pilots' outcomes, and the best available experience, then getting input from all stakeholders for the best decision.

Evaluation of the technology is about the standards to follow for the innovation and change that will come as part of an overall Digital Health strategy. Other strategic goals directly impact standards and need to encompass organizational and operational leadership and governance, investments, and workforce. There should be a means to approve and conduct pilots across different ecosystems while providing advisory and consultation support. Digital Health leadership would have much input into the sustainability, spread, and scaling of successful innovations.

Selecting a method for evaluating Availability Criteria, then the value of a tool through Quadruple Aim-based outcome measures is a vital strategy responsibility. Collaboration with clinical partners in the organization to get buy-in to positively affect workflows, time, expenses, and integration, while dealing with unintended consequences, e.g., expectations regarding higher standard of experience with virtual communication. Leadership would have input into payment model design for new care models to improve the patient experience while meeting both payer and provider financial expectations. A key role would be to formulate a plan to place technological applications into the community for population health interventions. The strategy should look at the social determinants of health to use technology to alleviate those detrimental factors to access and clinical outcomes.

There are no excellent established value and impact-based business models for Digital Health. Next-Generation Payers and Providers (NGPP) may be a good starting point since a provider stakeholder is directly involved. These companies were created to deliver a re-imagined service to patients, prioritizing health, and outcomes over utilization. The onus is not placed on the consumer or patient. The payer and the provider have direct risks and ultimately share responsibility for the customer and patient's health and care and Healthcare.

As a starting point, any Digital Health's strategy should consider short-term goals for both the consumer and the stakeholders. We all want our members and patients to have convenient, safe, effective virtual care. Both payers and providers see the value in doing a better job at managing chronic conditions, improving medication adherence, and reducing unnecessary emergency department visits and hospital admissions. Focusing on the elderly and the poor and the disadvantaged racial groups and those social determinants negatively impacting health is vital. Directing patients toward timely and appropriate care at the right location can begin today. Finally, we can use Digital Health tools to facilitate looking after the whole person's overall health [13].

Drury et al.'s working paper on investing in Digital Health provides a guide on how to think about the process. It can help put together the data needed to allow for a well-informed investment decision through the Digital Health Impact Framework (DHIF Appendix 2 pp. 56–59). The DHIF includes a list of crucial questions for each stakeholder to consider:


6.What are the priority actions within the resources available?

7.How will the results be monitored and evaluated?

In building the investment case, it will be important to show that:

i.The proposed initiative is needed and fits well with other relevant strategies.

ii.It represents value for money.

iii.It is commercially viable.

iv.The main investors, who may not be the direct beneficiaries, can afford it.

v.It is achievable.

A means to measure, monitor, and improve performance is mandatory. The Digital Health Impact Framework's (DHIF) consistent methodology provides an appraisal of estimated costs, benefits, net benefits, the socio-economic returns, and financial affordability over time of individual digital health projects. It enables bespoke appraisals that can be aggregated to help leaders and planners to:

(i) Understand and develop the socio-economic and financial aspects of their digital health strategies, modify them as needed, and (ii) Make informed investment decisions for sustainable digital health programs and projects.

DHIF is a proven methodology used in over 60 evaluations. It starts by setting a timeline that broadly matches an investment's life cycle. Then, researchers can prepare assumptions and estimates of types of users and stakeholders for each year. DHIF should include estimated changes from Digital Health projects, such as healthier citizens and communities, and more appropriate health care utilization. These arise from Digital Health's impact on patients, care providers and citizens, health workers, and health care organizations.

Drury et al. also propose that for any implementation to be successful, while leadership is the key, investment is necessary. This investment must come with clear justification by understanding the context and process for such investment decisions. Success also depends on better data management, including integrating and sharing data, agreement on policies and standards, good security, and all stakeholders getting needed resources. They felt that most digital health investment decisions would do well financially concerning affordability and return on investment and support the workforce population's overall productivity in general.

Here are the important components for strategy from Drury et al. [14] (Author comments have been added):

Leadership and governance- (to identify the preferred leadership and governance model), the collaboration between clinical and business sectors is vital. We favor a dyad that would direct strategic planning and implementation. Each partner comes with unique training, experience, knowledge, and skills to positively impact the Digital Health program. However, governance must include other stakeholders: payer, clinicians, patients, technology, marketing, finance, and patient experience. Success depends on full collaboration and cooperation, which must be a high priority and responsibility of these two leaders who have authority at an executive and enterprise-wide level.

Strategy and investment- (to produce a description of the Digital Health strategy and investment components required to support the development and operation of

the program) Drury et al. have four key focus areas which we believe should guide all strategic and investment goals:

