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/
MY LIFE PLAN is an online adult weight management plan. It was created by MoreLife, a subsidiary company of Leeds Beckett University which provides programmes and services to individuals to help them change their behaviours.
MY LIFE PLAN is promoted by NHS England as one of three digital options for those wishing to live a healthier life.
Produced by a small team, MY LIFE PLAN takes a scientific approach to weight management, looking at the whole person. “It’s not about calories in, calories out,” said Howard Samson, Digital Product Manager. “We look at sleep, exercise and portion size. This isn’t a quick fix, it’s a lifestyle change.
“When it comes to our competitor apps (like Noom and Slimming World), we are a small fish in a big pond but we are unique in that we give a very personal touch, with one-on-one coaching from dieticians as part of our level two offer. A lot of people come to us when they’ve tried and failed with one of the bigger names and want to do something different.”
When MY LIFE PLAN first launched with NHS England in April 2021, such was the demand that extra dieticians were recruited almost immediately. To date, two thousand clients have joined the 12- week programme and there should be capacity for 30,000 per year in the longer term.
As an NHS supplier MY LIFE PLAN needed to complete the new DTAC (Digital Technology Assessment Criteria). The team was aware this would be a complex, lengthy process not a quick fix and that being DTAC-certified was a moving feast. They could pass one day and on the next day one of the many regulations against which they’d been measured could be changed or added to, or they’d update their own programme, and they’d need to re-submit.
MY LIFE PLAN selected ORCHA as its partner for the DTAC. The process took five months and was achieved in a series of steps, with sections submitted and feedback given.
As part of the DTAC, the programme was tested against usability and accessibility plus its technical security and robustness. The DTAC also considers clinical safety and risk, medical device regulations, data protection and user journeys, amongst many other factors, depending on the nature of the product.
Where the developers needed more support, ORCHA offered subject specialists to give clarification. For example, when the security of the programme was raised, the ORCHA review team put Howard in touch with colleagues who were experts in penetration and performance testing. This approach was also taken with the data protection element of the programme.
The MY LIFE PLAN team were conscious that keeping on top of DTAC requirements was not a one-off job but a continuous process and it was recommended that they signed up for an ORCHA subscription package, so that their programme could be kept in a ‘compliance vault’ and regularly reviewed against any regulatory or in-programme changes.
Howard said:
“The DTAC is brand new, so we have nothing to compare it to but I know we all feel we’ve had great support through a complex process. ORCHA’s experts have been very clear and have broken down all the complexity so it’s become manageable.”
Liz Ashall-Payne, founding CEO of ORCHA, said:
“We have many clients preparing to go through the DTAC with us. The process takes time, as there is a lot of documentation to gather. Also, if the developer team is small and they don’t have some necessary expertise in-house, it can be held up, although there are many areas where we can provide support.
“Our advice is to treat the DTAC as a live process and to gear up for frequent re-reviews so that your app or programme remains fully compliant once the initial certification is complete.”
If you would like more information, or to book your DTAC, please email hello@orchahealth.com
After learning about the benefits of the Digital Health programme commissioned by Our Dorset, Seven Integrated Care Systems Across the South West have also introduced the ORCHA system to empower citizens, increase their digital maturity, achieve consistency in Digital Health across the system and achieve cost savings.
A partnership of health and social care organisations working together, Our Dorset holds the ambition for its 750,000 residents to lead healthier, fulfilling lives supported by sustainable health and care services. But the ICS faces real challenges. Similar to many regions, Dorset is facing significant workforce gaps in nearly every area of care and its population is ageing, bringing more long-term conditions, and placing a growing demand on its services.
To address this challenge, the ICS understood the importance of breaking down barriers to the health and social care system in empowering citizens with digital health tools. It first aimed to lay solid foundations for public facing digital health and apps were agreed to be a key building block.
Recognising the barriers in culture to embed the offering of digital health tools being firstly awareness and secondly accessibility, Dorset looked for a partner that would provide a single point of navigation both for the workforce and population in surfacing digital health tools in a simple way. Rather than select point products , it identified ORCHA as its partner in enabling a comprehensive closed loop system for all of the ICS digital health needs. The partnership with ORCHA enables continuous horizon scans, identifying the best technologies and developers to work with. The clinically designed evaluation process assesses these digital tools against relevant measures and if appropriate, surfaces them in a library that has a good user experience in searching and filtering to download and use such tools by choice. It continues to re-evaluate each tool when a developer does an update which helps assure the ICS and recommender on the safety of such tools. Its closed loop system also safeguards product and regulatory changes.
So in early 2020, Our Dorset commissioned ORCHA to assess digital health, develop a formulary of digital health products for priority areas, build a bespoke health app library demonstrating its use to the workforce and empowering them in how to signpost, and where commissioned prescribe digital health tools. With ORCHA, Our Dorset delivered a programme that mitigated risk and assured clinical teams they are recommending safe apps during the pandemic to enable accelerated access to services from home.
When the AHSNs, CIOs and CCIOs from across the South West learned about the programme, the benefits of rolling out the system across the South West were clear. As although digital health had been adopted across the South West, it had only been part of other initiatives. For example, digital health was used in programmes to address remote monitoring and COPD.
Because of this, and other Digital priorities, no single role had taken a step back and taken a holistic system wide oversight to digital health and the culture change for such services in its entirety. What Our Dorset demonstrated is that when a system wide perspective is adopted for digital health, benefit is seen across the whole health and care system, not just condition or issue-specific pockets.
Transformation Boards universally agreed that the solution would particularly add real value in the prevention space, easing pressure on the system. They also reported that it should not be viewed separately to COVID, but part of the COVID recovery plans.
Faced with an already stretched workforce, concern was expressed around resource requirements. However, as Our Dorset managed the programme led by one person, bringing in wider teams such as clinicians and marketing when needed, for a period of months; this concern was allayed.
The seven ICSs commissioned ORCHA to manage digital health assessment and distribution across the South West. All seven ICSs would collectively benefit ORCHA’s governance and assessments, including Digital Technology Assessment Criteria (DTAC) a baseline for digital health technologies to adhere to, enabling patients and the system to adopt relevant, safe and innovative technologies more quickly. This meant that staff and patients would have access to a consistent digital health toolkit, whilst each ICS would have its own digital health library, giving it the flexibility to choose its own health priorities and maintain its own brand. With Our Dorset being the host organisation, all organisations have signed up to the programme individually.
It was agreed that in every organisation, the roll-out would be led by Primary care. Each then looked for governance in which to anchor its deployment; this could be long term condition management, personalised care, healthy ageing, or anticipatory care, as they all share common ground with digital health benefits.
Each ICS worked with ORCHA to build its own personalised app library, giving professionals and the public to assess apps, and highlighting what good looks like for digital health tools. To assist, Our Dorset gave examples of areas they have seen good traction, including wellbeing, weight management, smoking and Musculoskeletal (MSK).
To aid workforce adoption and empower the skills and knowledge to use the app library and trust the digital tools featured, training was rolled out across a range of cohorts. Feedback was positive and teams valued that the system can act as their horizon scanning tool for new technologies.
To help assess the impact on workforce digital readiness, pre and post deployments were conducted across every ICS.
The seven organisations in this programme now have a system-wide approach. They have a single point of navigation to a wide range of digital health tools across long term condition management, wellbeing, screening and diagnostics, assured they have undergone due diligence.
It is essential today that digital literacy is made a priority for any workforce. The training programme delivered as part of the roll out helped to educate staff on digital health, giving them the professional development and confidence to recommend digital first. With staff shortages, having consistent training and tools also gives the system flexibility in movement.
Commissioning and managing the system across seven ICS areas is not only delivering consistency for staff and patients, but it is also delivering cost savings. Comparing the roll-out to a single organisation the group has reduced costs by thirty per cent. This doesn’t even take into account the cost savings delivered by each digital health technology tool within the app library that helps individuals better manage their health.
Since launching its programme, Our Dorset has seen significant impact. As they prepare to launch their libraries, the other six ICSs across the South West will be looking to achieve similar results. As in Dorset there have been almost 37,205 pages viewed on the site (up to the end of July 2021), and in one month alone, the app library achieved nearly 5,500 page views. Social prescribers are actively recommending apps to service users and vitally, this advice is being acted upon, with almost 2283 apps recommended to date and 56% of recommended apps downloaded, which is a very good engagement rate, especially compared with other services. The most popular search terms include Mental Health, MSK, Dementia, Diabetes and Cancer. Some of the most popular apps to be viewed are Wysa: Stress, Depression & Anxiety Therapy, Sleepio, NHS Weight Loss Plan and Musculoskeletal (MSK) Self Care, providing a range of health interventions and show that apps are being selected to improve the physical and mental health of the population.
The roll out has put in place the coordination needed to assure that the digital health technologies recommended by a team of 2,800 professionals across almost 50 organisations within the 7 ICSs, consistently not only meets standards, but pinpoints the best solution for every patient, in the 5.6 million population it serves.
Commenting on the programme, Crystal Dennis, Interim Lead for Digital Access to Service @Home, Our Dorset Digital, said:
“After Transformation Boards learned of what had been achieved in Dorset, everyone was unanimous in the view that it was a no-brainer to roll out an app library powered by ORCHA across the seven ICS organisations. For safety, practical and effectiveness reasons, it’s a foundation platform that every part of the health and social care teams should have access to.
“It is possible for an organisation to get to where we are now. But it will be harder, take longer and cost an awful lot more.”
Mental Health is a significant challenge for health services in the Netherlands. Depression has the highest burden of disease of all health conditions (8.2%), including cardiovascular diseases and cancer (1). To address this growing demand, professionals have identified that digital health can be useful in treatment, enhancing and extending services. But they haven’t used it extensively, as there has been uncertainty around which products are good. Professionals wanted digital health to be assessed before recommending it to patients.
Yet at the same time, people experiencing mental health conditions have been increasingly using apps. This has typically been approached informally by trial and error or asking peers. But this approach takes time, requires persistence and isn’t informed by evidence.
So in 2019, the Ministry of Mental Health Services put in place the funding to establish a programme to evaluate health apps, putting in place the tools to enable digital health to be safely part of mental health recovery services. With this funding at the end of 2019 ‘MIND’ – in co-creation with ‘de Nederlandse ggz’ – started the development of www.ggzappwijzer.nl, which was eventually launched in the beginning of 2021.
To be guided by evidence MIND reviewed scientific papers to understand if apps really do help. Once it was confirmed that there are good apps that do provide a positive impact, they researched how people find and choose apps.
As there is very little research into how people choose health apps, the team conducted experiments themselves. They discovered that searches result in hundreds of app suggestions, with no trusted information to indicate which are good.
Focus groups revealed the information people want when choosing an app. They don’t just want a score, they want the facts behind this. Basically they want to know three things:
Also people are interested in the opinion of others about an app. Do peers and/or professionals give some kind of appreciation or depreciation of an app?
Whilst researching the sector, the team learned about the Organisation for the Review of Care and Health Apps (ORCHA), and the hundreds of assessments it had already conducted on mental health apps. The team felt that the ORCHA assessment was objective and thorough; they liked how the assessment publishes not only a score but also the additional information sought. Further research revealed that every question the MIND team had developed to assess an app, ORCHA had already asked it. In fact ORCHA asked more questions the team couldn’t possibly answer within a reasonable balance between costs and benefits.
ORCHA’s comprehensive base of reviews, together with its work with the NHS, led MIND to work with ORCHA. This collaboration was more appropriate for the programme than trying to reinvent the wheel.
The programme decided to utilise ORCHA’s objective reviews and layer on top its own qualitative assessment information. For this additional layer, MIND arranged for 4 to 8 people to test an app for two weeks, after which each participant answers a structured questionnaire containing 20 (of quantitative and qualitative) questions. Questions ranged from ‘How easy was this app for you to keep using?’, ‘To what extent would you recommend this app to other people?’ to ‘What improvements do you suggest to improve the app?’. Participants included both professionals and people with mental health conditions. The feedback has been consistent from both groups, each bringing a different but each other reinforcing perspective. The individual testing reports were transformed by the MIND team into one consolidated summary, which functions as a preview of what someone can expect from this app.
As part of this programme, almost 100 digital health products have been through the ORCHA evaluation and 20 of these have been through the additional MIND structured questionnaire layer. It is hoped this second figure will reach 50 by the end of this year. The evaluated products are hosted on a website that can be easily searched by everybody who is interested in mental health apps. The website is also useful for health care professionals to give advice about using a mental health app.
Since its launch in January 2021, the site has been visited 35,000 times and feedback has been extremely positive. People welcome the trusted information on the apps that are in the library. This has been especially important during lock-down, when an increasing number of apps from un-reputable sources have been launched.
To reach more people, the library of reviews is now also integrated into QULI, one of the major personal health records in use in the Netherlands, as part of the Medmij programme.
The combined ORCHA assessment and MIND reviews have also enabled the team to have informed discussions with developers of digital health. They have provided developers with clear and actionable advice on how their product can be improved.
Commenting on the programme, Rimmert Brandsma, Project Leader, eHealth, MIND, said:
“The relationship between MIND, de Nederlandse ggz and ORCHA has also been very successful. There is huge synergy and I feel the end product is better having all partners working actively together.
“We look forward to the next steps, of making multilingual versions of the website and increasing the number of apps assessed, possibly including AI, VR and wearables into the assessment structure. This will help us to support even more people to find the best digital health.”
(1) https://www.oecd.org/els/health-systems/MMHC-Country-Press-Note-Netherlands.pdf