The Digital Front Door

Investment in digital health rocketed to a whopping $14.7B in 2020, and as Rock Health reported, and that total has already been exceeded in the first half of 2021. According to McKinsey, tele-health usage rose to a peak of around 78x in April 2020 and has now stabilized at 38x from a pre-Covid baseline. This increase has been driven by several factors including: consumer and provider willingness to adopt tele-health platforms, regulatory changes for clinicians to consult remotely and new reimbursement models for virtual care and remote monitoring. Additionally, training on remote consultations, supply of hardware including laptops and headsets connected to secure networks, and adequate legal protection have all enabled clinicians to practice remotely and safely.

These factors have led to a shift for tele-health and virtual care platforms from focussing not only on direct-to-consumer (D2C) channels but also to accelerating their business-to-business (B2B) channels; strengthening their partnerships with large health systems, with a desire to build something that health systems really want. With consumers, providers, payers, regulators and developers on board, few would disagree there has ever been a better time to explore how we re-design care delivery models at system level and how patients or citizens access care, through the “digital front door” so to speak.

In this article, I define the core constituents of a digital front door as: navigation, triage tools, shared care records, interoperability, virtual care platforms and remote monitoring tools, a fit for purpose workforce, and digital inclusion. These are the elements I encourage both health systems and digital health startups to consider when designing their virtual-first models of care, with the ultimate aim of streamlining access to healthcare services, increasing efficiencies in patient pathways and clinical workflows, reducing overall healthcare costs and of course, improving patient experience and outcomes.

Navigation

When we talk about re-designing the digital front door, we aren’t just talking about the speed at which a patient can be connected with a physician through a virtual care platform, or discussing how an employee accesses services through their health plan. We are talking about re-designing how primary care providers and health systems manage patient demand, develop consistent, system-wide routes that navigate patients to the most appropriate healthcare provider or resource for their concern, ensuring that patients who need urgent care receive timely access to services, and making patients feeling seen and heard in a tech enabled system, all whilst avoiding inappropriate use of primary care and emergency room services.

Writing for Omers Ventures, Investor Chrissy Farr, defined the range of navigation tools used in healthcare, categorizing them as: general navigation, verticalized navigation, embedded navigation, health advocacy navigation, and front door navigation. Technically this article refers to front door navigation, which is a huge value creation opportunity for startups to work with health systems to re-design access to services.

Mapping out user journeys can be a helpful way to evaluate existing pathways to services and provides insight into services that users are currently accessing or would like to access for their health. Service re-design could mean navigating patients directly to allied health professionals such as dentists, pharmacists, physiotherapists, nutritionists, sexual health clinics, midwives and health visitors without prior consultation with a primary care physician. These are all services which users can efficiency “self-refer” to and are potential B2B opportunities for startups to plug in and play with health systems. From a payer perspective, this improves user experience, improves access to appropriate services and also reduces costs.

On a systems design level, single point of access hubs, such as adult social care hubs, mental health hubs and community nursing hubs could also be accessed directly by patients and families. Not only does this align with a virtual-first care delivery model, but also streamlines pathways, avoids delay in intervention and increases patient and carer satisfaction. With appropriate reimbursement schemes, hubs can be particularly advantageous for delivering complex, multi-disciplinary care and provide an interface for primary and secondary care coordination.

“We are re-designing how primary care providers manage patient demand, navigate patients to the most appropriate healthcare provider or resource for their concern and ensuring that those patients who need urgent care receive timely access to services, all whilst making patients feeling seen and heard in a tech enabled system.”

Triage tools

When it comes to digital front door products, health systems are seeking ‘flexibly adaptive’ solutions which have core functionality with a level of customization, to account for regional/local variations in healthcare needs, individual personalization for providers, and collaborative working within and between healthcare organizations.

In terms of prioritizing patients, AI based symptom screening tools such as those developed by Babylon Health, go some way to help by booking patients with an appropriate clinician at the right time, whilst e-consults provide context for clinicians before a live consultation. The pandemic has revealed how virtual-first models such as telephone triage can in fact increase consultation times for providers, as clinicians spend time more time taking a thorough history from a patient, before arranging a face-to-face appointment as needed. In an effort to save clinician time Push Doctor have introduced virtual waiting rooms to enable patients to arrive before their clinician does.

Websites and landing pages play a key role in the re-design of virtual-first models of care for health systems, not only for front door navigation and triage but also for signposting consumers to health education, approved Apps and online resources for health promotion and wellness, including mental health and nutrition resources, exercise programs, fitness trackers and support groups. Online registration and prescription re-ordering are other important features. Website providers are required to meet General Data Protection Regulation and Accessibility requirements in the UK. Tools such as Memora Health’s AI assistants have the potential to introduce empathy at the front door, by providing navigation and triage with a more welcoming approach, addressing routine queries and potentially preventing unnecessary emergency room attendances.

Shared care records and Interoperability

Back during residency (GP training in the UK), whilst working in the emergency room, I was often asked by patients why I didn’t have access to their primary care records. These days, an NHS Summary Care Record is shared between primary, secondary and community healthcare teams. It might not be perfect, but the key point here is that some data now follows the patient during their care journey, which they can also access themselves, online and via Apps.

EHR interoperability, often described as the holy grail, enables care teams to update the same record in real-time, and for clinicians from collaborative teams to simultaneously access a record to discuss a case. It also opens up the opportunity for prescriptions to be issued electronically by authorized professionals, such as an out of hours provider. Data privacy and security is of course a fundamental consideration here. Companies building in this space should meet the DTAC criteria in the UK and HIPAA compliance in the US.

From a payer perspective, sharing care records between primary and secondary care increases risk bearing by primary care physicians, reduces specialist referral and follow-up rates, and reduces secondary care investigations. It also introduces the opportunity for new value-based care models such as advice and guidance consults between primary care providers and specialists as well as new contracts for referrals to GPs with specialist interests.

Virtual care platforms and remote monitoring tools

On the physician side, requirements of an electronic health record (EHR) have become multi-fold, and include amongst others, navigation, triage, appointment scheduling, data sharing, video calling, messaging, labs/imaging ordering/viewing, clinical documentation, electronic prescribing, coding, search and analytics. The functionality of an EHR now makes it look less like a platform and more like an operating system. Hardware requirements and adequate processing power to run these platforms is an important health system consideration.

Zus’s recent $35M fundraise to deliver the first ‘build-a-bear’ electronic health record for startups, Microsoft’s acquisition of voice recognition and clinical intelligence platform Nuance for $19.7B, and Amazon’s launching of an EHR and HealthLake to analyze vast amounts of health data, demonstrate that big tech companies are heavily scaling their operations this arena.

Wearable data and remote monitoring solutions for both acute and chronic disease monitoring has significant potential to grow. When we understand what an individual’s baseline vitals and labs are, combine this with their medical history, and use AI and ML to detect a statistically significant changes, we will be able to apply algorithms to analyze, predict and anticipate the needs of patients and prevent an acute deterioration. Google is making some headway in this space through its research in health AI and its Care Studio platform.

Fit for purpose workforce

The past 18 months brought to light the current shortages in the healthcare workforce and how these shortages are set to escalate. By 2023, a shortage of up to 55,000 primary care physicians is expected in the US, and 7,000 GPs in the UK. In response, we have seen a diversification of clinicians providing first-line primary care services. These include physician associates, clinical pharmacists, paramedics, social prescribers and first contact physiotherapists. Reimbursement is available via the NHS additional roles reimbursement scheme (ARRS).

Just as secondary care is becoming a hospital-without-walls, primary care is becoming an integrated care system, a partnership between physicians, allied health professionals, local authorities and local communities. This system brings services such as palliative care and learning disability teams right to the front door, and enables patient access to the right people at the right time. Channel wise, that could involve a virtual-first appointment with one clinician and a hand over for a face-to-face appointment by the next. Axle Health offers an API to dispatch in-home healthcare professionals including registered nurses and phlebotomists to carry out services such as lab draws enabling virtual-first providers to be involved in the entire patient care journey.

Key Stakeholder Engagement

Re-designing care delivery on system wide level, would not be possible without stakeholder engagement and an understanding of respective incentives. This involves innovation teams including Chief Information Officers and change managers inviting participation from patients, community representatives, clinicians, administrative teams, executives and payers. Maintaining an understanding that buy-in for change may not occur on the first meeting and also appreciating where accountability lies.

As Bajwa et al., said “a multi-stakeholder team brings the technical, strategic, operational expertise to define problems, goals, success metrics and intermediate milestones.” Engagement and participation from all stakeholders creates a deeper understanding of the scope of works, and facilitates trial and experimentation of new ideas simultaneously. Nominated clinical champions can be advantageous in the trial and adoption of new platforms as a source of continuous feedback and monitoring during an implementation phase.

Digital Inclusion

Groups more likely to be excluded from digital healthcare include older people, people in lower income groups, those who are unemployed or homeless, people living in social housing or rural areas, people living with disabilities, those at lower education levels and people whose first language is not English. In the UK, this equates to 11.9m people (22%).

Anecdotally, early in the pandemic I discovered that while most of my patients were happy to start with a telephone or video call, some just felt more comfortable seeing me in real life. My older patients were more comfortable using their PCs and email to exchange information remotely rather than via text messaging on their mobile phones: some did not have smartphones, others were not confident using them, others did not have data, the font size on their phone was too small to read, or the keypads were just too fiddly to handle. The key here is that to widen accessibility, hybrid models are here to stay. As an example, Rezilient Health provides local CloudClinics which patients can attend to consult remotely with their physician via a large monitor, supported by an on-site nurse.

Non-traditional access points for healthcare such as food delivery companies or local religious communities, can serve as valuable access points for healthcare interventions. We have already seen how such strategies have been successful in increasing vaccination uptake. Digital inclusivity champions within regions and communities can also identify access points and serve as a bridge for those people who have been excluded. Sandeep Pulim, Chief Medical Officer of virtual-first care delivery platform Bluestream Health shared with me how the company’s integration with LanguageLine has significantly improved access by offering translation in 240 languages.

Predictions and Future opportunities

Reimbursement for value-based care models - Value-based healthcare models are those where providers including tech companies, physicians and hospitals, are paid based on patient health outcomes. Although uncertainties remain with regulations and reimbursement, as many were authorized in response to the pandemic, I anticipate future policy changes that will support the advancement of new value-based, virtual-first care delivery models.

EHR platforms or operating systems - Whilst tele-health providers have gained traction in this space, the market is rife for disruption to automate clinical workflows, increase interoperability, exchange health information more rapidly, code previously un-captured health data and provide search and analytics. With incumbent EHR providers unable to keep pace and big tech company efforts currently fragmented, opportunities lie here for companies to create a solid operating system, and for other platforms to plug and play.

Population health management - With large patient aggregated data sets in the hands of governments, health systems and big tech companies, we now have greater insights into patient populations, their health needs and their social determinants of health (SDOH). Analytics will identify populations at high risk of certain outcomes for which targeted health interventions can be developed, such as invites for cancer screening or structured weight loss programs. Startups have an opportunity to provide these interventions for payers on value-based care contracts right from the front door.

Companies building in public - With the evolving needs of health systems and patients accessing care through a digital front door, I anticipate more startups working collaboratively in real-time with end users, inviting them to engage in product iteration on a continuous basis. One example of this is the accuRx Public Roadmap which shares what the company is working on and what they are thinking about working on. Users are able to upvote their preferred features and also view the timeline for availability of upcoming features.

If you are part of a health system or a startup building a product, platform or API for the digital front door, drop a comment here. What else do we need to consider? I’d love to hear your thoughts.

Namrata Rastogi is a GP Partner, and part of an NHS Integrated Care System, Digital Front Door workstream. She also works as an advisor and investor in digital health.