Professor Nikki Cotterill and Knut Schroeder developed CONfidence, a discreet, informative health app for those experiencing continence issues.
Throughout her career, Professor Nikki Cotterill, an associate professor in continence care at the University of the West of England, had noticed that people experiencing continence issues could be reticent about getting help.
Embarrassment could be a factor but, often, people simply didn’t know that symptoms could be improved. Nikki said: “There’s usually a tipping point – people find out that a continence service exists and are given lifestyle advice and exercises. It’s common for people to say they wish they’d known about this ten years ago’.
“I was on a Florence Nightingale leadership scholarship and when I spoke to my group about this, we realised there was a gap in advancing the policy area. We thought an app was a good way forward. It wouldn’t solve all the issues but would be a useful starting point for a campaign.”
The challenge was, how to bring the app to life.
Nikki approached Knut Schroeder, founder of Expert Self Care, an organisation which co-creates health apps for universities, NHS organisations and local authorities. The two colleagues then identified a number of other key stakeholders to involve in their project: people who have lived experience of bladder and bowel leakage, national experts and organisations specialising in bladder and bowel care.
Working with ORCHA
The development of high-quality content for the app was just one of the challenges faced by the team. Based on his experience of co-creating a number of other apps, Knut knew that accessibility was an issue. He said: “The key is to have simple information – but links if people want to find out more. It’s a bit like a TV remote control. I don’t know what 80% of the buttons do! So, we strip out things that people never use and don’t understand.
“We do tech updates as we go along and our editorial updates are ongoing. In fact, every page has a review date on it. We are required to update certification of the overall app every two years but we voluntarily state the next review will be within 12 months.”
As he had with other Expert Self Care apps, Knut opted to have CONfidence assessed by ORCHA’s baseline review, which would measure it against 350 tough standards and assess it for clinical efficacy, data privacy plus usability. He said: “In the past, I’d had really great interactions with ORCHA and this review helped, too. We knew where to improve, what to work on, where we could do better. All our apps have scored above the ORCHA quality threshold, which means they are distributed to healthcare professionals via app libraries. This is a great way to get them used and get the work out.
“Our app is generic for a UK audience but local areas can subscribe to optional local pages. Some areas have great information already but others are struggling and are not as coordinated.
“We have found that having an ORCHA score is really helpful for getting the trust of those organisations. Once they see the ORCHA badge they find it easier to trust the product. I hear that quite often commissioners don’t know which digital tools to recommend or use – they don’t have the time and skills to assess them. So having this independent ORCHA verification is really useful.”
It was Nikki’s first experience of working with ORCHA. She said:
“From my personal experience, given that I’m a nurse and researcher and have never done any app development, all my engagement with ORCHA has been really supportive, helpful and understanding.”
An award-winning app
CONfidence is now available on the ORCHA app library, with a score of 74%, reflecting its high standards. It’s a free-to-use national information hub with over 70 quality-assured articles on key topics about bladder and bowel leakage.
It enables health, care and education providers to offer the very best health and wellbeing information – instantly available in one convenient place, covering topics such as the causes of incontinence, treatments, and products which may help. It even supports families coping with the challenges associated with young children: potty training, bed wetting and continence at school.
Knut said:
“The app is regarded as a complex public health intervention. Even though it’s not classed as a medical device, we are giving out a lot of information. We are currently working on pathway development within clinical pathways, focusing on GP, bladder and bowel and maternity services in local areas.”
Many services are using CONfidence as a first-line intervention and it’s been referred to as a ‘gamechanger’ in continence services. This year it won a Nursing Times award for continence promotion and care.
With one in four Nordic citizens 65 years or older by 2040, and a growing proportion of people with one or more chronic diseases(1), digital health is seen as a vital component for a sustainable health system.
Delivering a future of a more patient-centred and sustainable healthcare service, digital health enables care that is personalised, convenient, engaging and available 24/7. Accessed by the tap of a button, digital health offers new ways for people to access support before, during and after traditional care.
This appeal has led to increased adoption of digital health(2), and there are now 5 million health apps downloaded every day across the world.
Digital health can also help health systems, particularly in assisting with distant care – giving patients contact with professionals through digital health solutions – and also having more digitally involved healthcare pathways, which would ease the burden on the traditional healthcare system.
In the Nordics, there is a need to ease the burden on the traditional healthcare sector, a need to digitalise healthcare processes for professionals, and also a need for greater focus on preventative care. Digital health provides a potential solution to each of these challenges.
As a result of these challenges, a vision came about across the five Nordics countries called the Nordic Health 2030 Perspective. The Nordic Council of Ministers – the cooperation between these five countries – decided in 2018 that, by 2030, they want to see the Nordics as the most sustainable and integrated health region in the world, providing the best possible personalised healthcare for its citizens.
In the middle of 2018, this ambition became the starting point for an initiative that aimed to integrate healthcare and the sharing of health data across the five Nordic countries.
On behalf of the five Nordic countries, the Copenhagen Institute for Futures Studies created the Nordic Health 2030 Report. In this report, it was noted that the Nordic welfare system was not sustainable because, currently, there is an approximate spend of 10% of GDP on healthcare (that is, treatment beginning when a patient becomes unwell), and only 0.3% on preventative care. As such, the report pointed towards the imbalance in the Nordic welfare system, and the need for a much greater focus on preventative care. Five aspirations were defined in the 2030 Report, one of which was to increase the focus on preventative care, while at the same time easing the burden on the traditional healthcare sector.
In light of this, the Nordic Interoperability Project (N!P) is working towards establishing the Nordics to be the first region in the world to establish common cross-border standards. This will enable patients to live and act in an open, seamless, cross-border healthcare ecosystem, by showcasing and implementing world class solutions and innovations from the Nordics.
Anders Tunold-Hanssen, CEO and Project Manager of the Nordic Interoperability Project (N!P) since 2018, explained that: “We knew, when working on the Nordic level, that we had to look for solutions where we could involve the citizens more and help them to easily get access to preventative care actions, in such a way that we could even out this unbalanced equation.”
Upon hearing about ORCHA’s work with the NHS in the UK, and national bodies across the world, to get safe digital health solutions into the hands of citizens, Anders, CEO and PM of N!P, realised the tremendous impact that getting health apps into the hands of citizens could have on increasing preventative care.
Speaking about ORCHA’s work, Anders noted that,
“in my mind, [ORCHA’s work] was a perfect example of how to get the citizens involved, and to gain more focus on preventative care.”
N!P then began collaborating with ORCHA to explore their cross-border vision for the five Nordic countries.
When N!P first started collaborating with ORCHA, they knew that the five Nordic countries had an ambition to increase focus on digital health. However, none of the five countries had started out with any quality assurance programmes or guidance, for neither the citizens, healthcare professionals, nor the digital health suppliers, in terms of how to separate good digital health solutions from not so good ones.
With the Nordic 2030 vision in mind – to be the most integrated health region in the world by 2030 – N!P saw that there was little use, in this small region of the world, in developing five separate digital health systems, instead of working towards one common solution. N!P saw a collaboration with ORCHA as a way to achieve their cross-border vision for digital health in the Nordics.
N!P also reached out to the Nordic Council of Ministers and their innovation organisation, Nordic Innovation, to get the funding to get the project up and running. The project was planned to take place over a two year period, in which N!P wanted to utilise the knowledge and the competence of ORCHA, and build upon ORCHA’s previous work in the digital health space, to meet the five Nordic countries’ requirements.
Anders explained:
“We said very clearly when we started out with this project, to the Nordic community, that we didn’t want to start from scratch – we wanted to build this on the best experience out there, and everyone was pointing towards ORCHA.”
The project started out with the ORCHA Baseline Review as the foundation for the Nordic digital health accreditation framework. N!P then invited a wide stakeholder group from all over the Nordics to look into the components of the ORCHA Baseline Review and give their input into changes, alterations and additions, which created what is now a starting point for a Nordic baseline review. A lot of the Nordic accreditation is similar to what is being evaluated in the UK, but more specific components are included to meet needs in the Nordics.
N!P is now at the stage in the project where they have a Nordic baseline review as a draft, so their next step will be discussing and agreeing this review with each of the five countries. The Nordic baseline review is open for country-specific requirements if needed, but N!P has also advised that, whenever there is a national initiative, the aim should be to see if this can also be a wider Nordic requirement. This works towards the aim of having, as much as possible, a common solution across the five countries, with as little as possible being national-specific.
The different segments of the healthcare sector are interested in different review components, and all of these are important, but, being the Nordic Interoperability Project, N!P has a special interest in interoperability: how to make sure that the data collected in digital health solutions in the future can be available across the healthcare system.
Currently, in the Nordics, there is the same challenge as that faced by many other countries – data is being stored in doctors’ offices or in hospitals, but it is hard to share this data as it is built on different standards and stored in different places. Thus, systems’ inability to talk to each other poses a huge problem. One way of resolving this challenge is to establish interoperable solutions and standards to try to get data out of one system and connect it to the data in another system.
From day one of the project, N!P set out to try to make sure that the data stored in any of the digital health solutions approved for the Nordics was following some common standards on interoperability in such a way that, further down the line, the data collected in these different digital health solutions could also be utilised. For that reason, interoperability, the sharing of data, and the storage of data, based on international interoperability standards, is extremely important. If digital health suppliers want to have a solution approved for the Nordics, N!P aims to ensure that they are following some form of international interoperability standards.
Since the five Nordic countries are, individually, quite small, N!P found that having common accreditation requirements also creates huge potential to motivate digital health suppliers to develop solutions that could be approved for five countries at one time, instead of going through five different accreditations on defining quality. The digital health accreditation has to be easy enough for digital health suppliers to want to go through it, whilst also upholding quality standards. N!P is working with ORCHA to bring this quality assurance process into a centralised place across the Nordic countries.
Digital health suppliers need a cross-border accreditation, as, currently, it is quite easy to develop and launch digital health solutions, but very difficult to get traction and to get across the tipping point where it is a business sustainable solution.
For instance, within healthcare, professionals could find a digital health solution that meets their needs, but it is not business viable for only one hospital to use the solution. For that hospital to be able to have quality solutions, it also has to be easier for the digital health suppliers to get a bigger marketplace, so that their digital health solution is sustainable.
N!P believes that, with cooperation between the five countries, having as many requirements as possible as common requirements, will make it easier for digital health suppliers and will motivate them to go through the quality assurance process. Resultantly, suppliers will see that they have a bigger marketplace where they could potentially build a sustainable business.
The Nordic baseline review will be closely connected to the ORCHA Baseline Review and other international baseline reviews, in order to make it even easier for the internationalisation and globalisation of digital health solutions. The Nordic solution is to adjust the review to national demands, whilst simultaneously keeping it as close to international reviews and frameworks as possible.
N!P is planning to do pilots of the Nordic accreditation framework during Autumn 2021, to test the system and also to invite digital health suppliers to give their input on the process.
The idea is that N!P will also have a digital health library alongside the accreditation – a Nordic ‘warehouse’ of digital health solutions. After working with ORCHA to create a centralised model for approving solutions, the Nordic digital health library will make it easy for Nordic healthcare authorities to access the quality assured solutions. Wherever a solution in the Nordics, or a solution outside the Nordics wanting to enter the Nordic market, has gone through the review process and has been stamped as a quality assured solution, those solutions can be made available in the Nordic library for national platforms to access them.
As the project is a cross-national border initiative, rather than a national one, N!P wants the library to be a place for national platforms to find quality assured solutions for the Nordics, so that all five national authorities can be in control of which solutions are being offered to their professionals and citizens – N!P’s digital health library will give them the means of having a source to find such solutions. The idea is that professionals will then be able to recommend digital health solutions to their patients, either via the Nordic library, or a national sublibrary.
N!P will now, in continuous dialogue with the national authorities, start promoting the potential of digital health to citizens and professional healthcare workers in the Nordics. This Autumn, N!P will run webinar, seminars and information packages on the potential of digital health solutions, open to anyone in the Nordics, so that anyone who wants to be more informed and to start looking into the potential of digital health, will have the opportunity to do so.
Anders explained the decision behind working with ORCHA on the N!P initiative for a Nordic digital health accreditation and library:
“The whole story behind ORCHA, and also the work that ORCHA has been doing for several years in the UK and other countries, fits very well with the thoughts we had in the Nordics, so it was a really good fit. And the more I talked to different people and different health authorities, not only in the Nordics but also outside the Nordics, everyone who had started looking into quality assurance of digital health solutions, all of them pointed towards NHS and ORCHA.
“So, for that reason, the confidence in ORCHA just grew by being looked at as the go-to place for a lot of different authorities. Whenever I talked about evaluation of digital health, someone in the meeting room or presentation said they had been looking at ORCHA and that they had been doing a lot of good work.
“From that perspective, we found that ORCHA seemed to be the leading organisation for quality assurance of digital health, and since we have quite an ambitious goal [with our 2030 vision for the Nordic countries], we saw it as better to then join forces with ORCHA and build upon the knowledge and the solutions that they already had, instead of trying to start doing something similar from scratch in the Nordics.”
In many respects, N!P’s project is very similar to what ORCHA is doing with the other national initiatives they’re working on, with the difference being N!P is trying to achieve a common digital health accreditation across five countries. These five countries have a history of cooperation and they have a Council of Ministers that work together, as well as a Nordic welfare model, meaning that the system and setup within each country is quite similar.
While some countries are big enough to build business models behind their own country, in the Nordics, as with rather small countries, specialised solutions need a bigger marketplace that one country alone can provide. The cross-national solution in the Nordics hopes to give digital health suppliers significant enough business grounds for them to build sustainable solutions that, as a result, have longevity in providing integrated, quality assured digital health solutions for professionals and citizens across the Nordics.
(1) https://norden.diva-portal.org/smash/get/diva2:1297054/FULLTEXT01.pdf
(2) https://www.statista.com/statistics/1092869/global-digital-health-market-size-forecast/
Published in: BMJ Open
The traditional model of healthcare delivery is based on providing medical services through systems of hospitals, primary care facilities and outpatient clinics. However, the COVID-19 pandemic has profoundly disrupted the routine delivery of physical healthcare, resulting in the widespread deferral of elective, preventive and outpatient appointments by health authorities. Estimates suggest that as many as 40% of appointments have been cancelled or postponed by patients, as part of efforts to avoid public spaces as much as possible. In the USA, ambulatory care visits fell by 60% in the early phase of the pandemic, while in the UK alone, an estimated 1.5 million elective admissions and 2.6 million outpatient attendances were forgone as a result of COVID-19.
We explored if consumer interest in digital health products (DHPs) changed following the COVID-19 pandemic and the lockdown measures that ensued. We identified all web-based internet searches for DHPs in the UK using ORCHA app libraries, split over two periods, pre-COVID-19 lockdown (January 2019–23 March 2020) and post-COVID-19 lockdown (24 March 2020–31 December 2020).
There were 126 640 searches for DHPs over the study period. Searches for DHPs increased by 343% from 2446 per month prior to COVID-19 lockdown measures being introduced to 8996 per month in the period following the first COVID-19 lockdown in the UK. In total, 23/25 (92%) of condition areas experienced a significant increase in searches for DHPs, with the greatest increases occurring in the first 2 months following lockdown.
Musculoskeletal conditions (2.036%), allergy (1.253%) and healthy living DHPs (1.051%) experienced the greatest increases in searches compared with pre-lockdown. Increased search volumes for DHPs were sustained in the 9 months following the introduction of lockdown measures, with 21/25 (84%) of condition areas experiencing monthly search volumes at least 50% greater than pre-lockdown levels.
Our findings suggest that the COVID-19 pandemic has profoundly disrupted the routine delivery of healthcare, making face-to-face interaction difficult, and contributing to unmet clinical needs. This study has demonstrated significant increases in internet searches for DHPs by members of the UK population since COVID-19, signifying an increased interest in this potential therapeutic medium. Future research should clarify whether this increased interest has resulted in increased acceptance and utilisation of these technologies also.
Read the full research piece here: https://bmjopen.bmj.com/content/11/10/e053891
Published in: JMIR mHealth uHealth
Despite the increasing availability of mobile health services, clinical engagement and use of health-apps remains minimal. This study aimed to identify and prioritise barriers to and drivers of health app use among health care professionals (HCPs) from the United Kingdom.
A discrete choice experiment was conducted with 222 HCPs using a web-based survey between March 2019 and June 2019. Participants were recruited to take part via social media and asked to choose their preferred option of 2 hypothetical health apps to prescribe to a hypothetical patient or to prescribe neither.
Hypothetical health-apps were characterized by differing levels of patient age, cost, published evidence bases, whether they had a National Health Service (NHS) stamp of approval, personal familiarity with the technology, and whether they were recommended by a fellow HCP. These were all reported as important factors in deciding whether HCPs are likely to prescribe a DHT, based on our pilot study published in the Lancet digital health.
We received 230 responses from UK-based HCPs, a total of 96.5% (n=222/230) of respondents understood the survey task and passed the test of rationality. 62.6% (n=139/222) of the health care providers responding to the survey had previously recommended the use of health apps to patients. Health apps were most likely to be prescribed to patients if they had an NHS stamp of approval or if they were recommended by another HCP (both P<.001). Published studies detailing clinical effectiveness were important (P<.001), but it would take five published studies to have the same impact on prescribing behavior as an NHS stamp of approval and two studies to be as convincing as having used the technology personally.
Increasing patient age and costs resulted in significant reductions in digital health prescribing (P<.001), none more so than among allied health professionals. Willingness-to-pay for health apps increased by £124.61 (US $151.14) if an NHS stamp of approval was present and by £29.20 (US $35.42) for each published study.
Overall, 8.1% (n=18/222) of respondents were reluctant to use health apps, always choosing the I would prescribe neither option, particularly among older HCPs, nurses, and those who do not use health apps personally.
The results of this study suggest that an NHS stamp of approval, published studies, and recommendations from fellow HCPs are significant facilitators of digital prescribing, whereas increasing costs and patient age are significant barriers to engagement. These findings suggest that demonstrating assurances of health apps and supporting both the dissemination and peer-to-peer recommendation of evidence-based technologies are critical if the NHS is to achieve its long-term digital transformation ambitions.
About ORCHA
Founded by NHS clinicians, ORCHA is the world’s leading digital health evaluation and distribution organisation. We provide services to national health bodies across three continents, including the NHS in 50% of UK regions, delivering national accreditation frameworks, bespoke Digital Health Libraries, and professional recommendation tools, specific to the needs of our clients. ORCHA’s unique Review Engine assesses digital health solutions against more than 350 measures across Clinical/Professional Assurance, Data u0026amp; Privacy, and Usability u0026amp; Accessibility, plus additional criteria depending on needs.