Increasing access to digital technologies is changing how people manage their health and how health services are provided. However, implementing eHealth solutions on a large scale, for example, when aimed at a specific population or applying to a particular area, is not easy.
In the foreword to the guide, Dr. Soumya Swaminathan notes that such investments need to be thoroughly planned and thoughtfully coordinated, and it would be hard not to agree with her. Only strategically implemented solutions can generate added value in the long term and become a means to create well-being.
The appropriate use of digital technologies in health programs should be based on the Principles for Digital Development:
- Design with the User: understanding the needs and perspective of the end-user;
- Understand the Existing Ecosystem: well-designed digital tools consider the existing structures and needs;
- Design for Scale: achieving a high degree of adaptation of eHealth solutions requires designing beyond the pilot population and necessitates securing appropriate funding and a broad approach towards target groups;
- Build for Sustainability: ensuring a long-term and positive impact on the health care system;
- Be Data-Driven: using high-quality data;
- Use Open Standards, Open Data, Open Source, and Open Innovation: only this approach can contribute to increased collaboration and allow us to avoid duplicating work that has already been done by someone else;
- Reuse and Improve: instead of building anew, sometimes it is better to rely on available ideas and use them in a new context;
- Address Privacy & Security: data processing should be approached with particular caution and attention;
- Be Collaborative: sharing information, strategies, and resources across projects.
In the process of planning health programs which make use of digital tools, we should pay particular attention to the following elements:
- assessing the current state and the enabling environment,
- establishing a shared understanding and strategic planning,
- defining the future state,
- planning enterprise architecture,
- determining health content requirements,
- monitoring and evaluation (M&E) and fostering data use,
- implementing, maintaining, and scaling.
We need to remember that every health program, even if it does not contain digital elements, is an extended and time-consuming initiative that requires knowledge of project management. But what is equally important is an experience in digitalization projects, sensitive factors that determine the success or may lead to the failure of the implementation of digital solutions. What are the stages of this process?
1 - Form the team and establish goals
At this stage, the main element is preparing design documentation. It is necessary to determine the tasks of every person involved in the project. It is not necessarily active participation; many people can be assigned different roles, for example, those of an observer or a partner, who should regularly receive information on the progress of work. The organizational structure and clearly defined goals will make it easier to manage the project, focus on top priorities, and measure achievements. What also counts is understanding how the work of the team can contribute to global development. It is worth employing experts in various fields to form an interdisciplinary team with members who have different competencies and skills.
The team's first meeting is supposed to demonstrate to everyone why the program is being carried out and what its expected results are. Every project member should be familiar with the short- and long-term goals and understand how the project corresponds to the broader context of health care at every level of its local or national perspective. What should also be considered is to offer people from outside the health care system (such as the technical contractor) insight into the existing health program's functioning and explain to them why it is being modified. It is also necessary to specify the end-users (beneficiaries) of the program.
2 - Identify health system challenges and needs
Examining current processes and workflows and determining bottlenecks. A practical tool for analyzing the status quo and generating desired scenarios is CRDM (Collaborative Requirements Development Methodology), developed by the Public Health Informatics Institute. The CRDM approach states that it is necessary to define the problem (analyze the current process), rethink it (restructure business processes), and compile a list of requirements needed to change the current state (how the IT system can change the status quo). Another method of mapping processes are diagrams, which illustrate the user journey through the system. They are broken down into stages, events, and interactions and show the entire system's workflow. In the case of analyzing bottlenecks within the processes, it is worth paying attention to bottlenecks in three areas: physical (infrastructure, communication, etc.), human (program implementation), and organizational (processes or administrative and legal solutions which cause malfunctions).
3- Determine appropriate digital health interventions
This stage involves the design of digital health tools, whose aim is to improve existing health programs and to eliminate any bottlenecks identified in the previous section. It is also essential to recognize and understand digital maturity in a given target group so that the proposed change is adjusted to the existing technical architecture and use the existing resources to the maximum rather than duplicate them. At this stage, it is essential to understand the technical side of the project, including data safety standards and interoperability. The questions that should be asked are as follows: Can the end-user use digital health intervention? Are the ecosystem and the business environment conducive to its implementation? Will it be accepted? What will the target information flow be? Does the program correspond to health care priorities? Successful implementation of digital health applications requires in-depth knowledge about the health care ecosystem, information links, and other digitization projects, which may overlap with the proposed program in the future. It will not always be necessary to build an entirely new digital tool. In many cases, we can rely on existing solutions, which simplifies implementation and lowers costs.
4 - Plan the implementation
When the project has been drafted and thoroughly analyzed, we can plan its technical and organizational side. What is essential at this stage is communication with technology suppliers, a review of critical factors that affect the solution's quality, the development of a realistic implementation plan, and the specification of functional requirements. The WHO guide provides a list of questions that should be asked at this stage, concerning technical infrastructure, compliance with local and national provisions and strategies, the human resources required for the implementation, servicing of the solution, standards, and interoperability, and the approach towards data. The implementation's success depends on an appropriate preparation of end-users (training), the technical friendliness of the solution, and users' involvement. Implementing a digital health solution entails a change in existing work procedures and methods, so the authors propose using John Kotter's eight-step model for change management. Before the tool is adapted on a large scale, it is necessary to run usability and user experience tests, acceptance tests, functionality tests, and stability tests.
5- Link the digital health implementation to the enterprise architecture
This stage boils down to anchoring the solution in the architecture of the health care system of today and tomorrow. The new digital intervention should be oriented towards collaboration, data sharing, and integration with new solutions while avoiding siloed solutions. What is defined are future workflows and basic functional requirements for planned projects within digital health care enterprise infrastructure. It is worth considering how we should link the new solution with the existing ones and how the designed system can be used by other entities in the health care market. It also needs to be remembered that the solution will be further developed in the future. Designing it with a timeframe in mind and as part of the continuously developing health care infrastructure is of strategic importance (following the rule "build once, use multiple times").
6- Develop a budget
Only when there is a detailed strategy for the digital health solution can we develop a schedule of costs and choose the financing model. In order to do that, it is necessary to identify all cost drivers, from technical elements of the system to services and servicing the solution. We need to consider whether it is possible to gain financing from external sources and how to ensure the project's financial liquidity throughout the functioning of the program and when it is developed, not just today. One of the most common mistakes is underestimating the project's costs and ignoring the total exploitation cost (for example, additional expenditure related to transferring data or ensuring interoperability). The WHO guide includes a practical budget matrix with the most significant cost items.
7- Monitor the implementation and use the data effectively
Based on pre-established and measurable goals, the project manager needs to review the completion of subsequent stages of the project regularly (a checklist with elements that must be regularly monitored). However, this is not where the implementation stage ends. The change process needs to be strengthened all the time, and the use of the collected data needs to be promoted. Trust in digital solutions depends on the organization's approach towards gathering, processing, and sharing data. At this stage, what is proposed is adaptive management, which involves flexibly reacting to changing priorities and conditions in the health care ecosystem. Logic models are helpful here. They aim to explain the program's goals and determine expected causal links from inputs, processes, outputs, and outcomes. In order to maintain the proper functioning of the whole system, it is necessary to strengthen the culture focussed on gathering high-quality data.
8- Value proposition and next steps
The final stage focuses on generating added value from the project by adjusting to the environment, cost savings, and project evolution.
