Digital Health Accreditation in the Nordics: A cross-border initiative for integrated digital health provision

Situation

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.

The Nordic Health 2030 Perspective

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.

A cross-border vision

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.

Approach

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.”

Building the Nordic accreditation

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.

Quality assured, sustainable digital health solutions

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.

Nordic digital health library

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.

The cross-national Nordic solution

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/