Digital distribution of healthcare services

Organisations across many sectors have derived competitive advantage by owning the distribution channel for their products and services. Whether that's supplier relationship, store, branch or brokerage networks. The internet has eroded this barrier to entry by making distribution effectively free in many sectors thereby levelling the playing field and allowing new entrants to emerge.

Organisations are now faced with the need to differentiate their business models in new ways in order to compete and avoid being disrupted. Many are focusing on customer experience as the new battleground and investing in new enterprise architectures that leverage public cloud, APIs and target mobile.

But how does this trend affect public services, where competing to acquire new customers or prevent churn is not the major issue?

Below we have summarised our thoughts on why the NHS should use the internet as a complementary channel for the distribution of digitally enabled healthcare services, what functionality this new digital platform should offer and made a stab at how to go about developing it.

Why develop a digital health platform?

Healthcare services in Scotland are currently distributed through 228 hospital sites employing 67,000 nurses and midwives and 4,900 consultants, 980 General Practices with 4,800 GPs and 1,250 community pharmacists with 4000 pharmacists. In addition this network is supplemented by care in the community services.

There are well recognised macro trends that show that the current healthcare delivery model will be difficult to sustain at current investment levels. These trends are covered in depth elsewhere but are briefly summarised below:

An ageing population

Like many developed countries the population in Scotland is living longer with the old age dependency (OADR) ratio being predicted to move from 30% to 48% in the next twenty years. More people living with long term conditions will produce extra demand on both primary and secondary healthcare. As a result, the current delivery model (and associated quality standards) for health and social care services will not be sustainable on current investment levels.

Scottish Government's projections for health and social care demand (£m, 2009-10 prices)

Service	2010	2015	2020	2025	2030
NHS Services (for adults)	£9,375	£9,805	£10,310	£10,852	£11,389
Average % change p.a.		+0.9%	+1.0%	+1.0%	+1.0%
Residential care and home care for adults	£1,637	£1,825	£2,077	£2,396	£2,780
Average % change p.a.		+2.2%	+2.6%	+2.9%	+3.0%

Reference: Scottish Parliament Finance Committee (PDF)

Prevention, prevention, prevention

The top four killers of people under the age of 65 in Scotland are lifestyle driven diseases and more people are living longer with long-term health conditions. For example Type 2 diabetes, a preventable condition, is predicted to double in next ten years and the treatment of diabetes already absorbs 10% of NHS Scotland budget (£1bn pa).

The Christie Commission report clearly states the need to invest in preventative measures across the public sector to reduce demand: “Achieving a radical shift towards preventative public spending is likely to be controversial, but we consider it to be essential. High levels of public resources are devoted annually to alleviating social problems and tackling ‘failure demand’ – demand which could have been avoided by earlier preventative measures.

“But it is a reactive spending – targeting the consequences not the causes. Until now we have funded that ‘failure demand’ with annually increasing budgets. That is no longer an option. So tackling these fundamental inequalities has to be a key objective of public service reform”.

Smartphones, internet of things and consumer demand

Scotland is now a smartphone society (PDF). They have overtaken laptops as the most important device for internet access in Scotland. Over 165,000 mobile health apps are now available to monitor a range of conditions and improve wellness and 10% of these apps already have the capability to connect to a device or sensor to provide feedback on physiological function data.

And equally there is strong evidence that people want to play a bigger role in managing their own health by gaining access to their own health information.

So what is required to support the development of new digitally enabled health services that offer self-management, provide more flexible care options, reduce the ever-rising demand on primary and secondary care services while supporting prevention within a framework that can be governed?

What are objectives and scope of the platform?

We believe a new digital platform for healthcare should:

• support the development of NHS digitally enabled services that meet end user and health professional needs
• support permissionless innovation by allowing third party organisations access to the platform to develop services
• support sharing of data between health professionals and end users; and the sharing of data between different end user applications.
• enforce agreed national standards for APIs, metadata schemas and information security
• enable users to control which services can access their data – grant and revoke permissions to these services
• enable users to search for and discover services that meet their needs

Digital platform in details

Digital services

The platform offers four different categories of service:

• Official NHS digital services: GP appointments, prescription reordering, mydiabetesmyway, Renal etc
• Non NHS services: Approved services that integrate with platform and meet user and healthcare professional needs
• Device Apps: Single purpose mobile apps designed to sync data from connected hardware/sensors back to a healthcare professional
• Headless Apps: Applications developed to connect data between existing health platforms and NHS data stores

It is important to emphasise that the platform supports the development of services specifically for NHS healthcare professionals as well as end users. Whether this is an administration view of an end user service or a specifically developed services that pulls data from the platform.

Platform services

Some of the key things that the Platform services offers are:

• consistent interface APIs creating a federation of otherwise disparate data sources
• granular permission to access confidential data
• standards for information security and consent
• a chance for users to control their data that would otherwise be locked in inaccessible silos
• an opportunity for developers to create innovative solutions by mixing data from a number of sources
• shared authentication across services

Data stores

A key part of the platform will be the data store(s). The data stores will host data collected by approved services and enable NHS systems to push data to the data stores. Through API services the data store will provide real time access to data to all approved services with correct permissions.

For the first phase (using a platform prototype) we recommend that the data store should consist of a set of measurements. Each measurement comprising a type, value and date/time. For example types could include steps, blood pressure, weight, cholesterol, blood glucose etc. A service will register to the platform with an approved set of permissions controlled by the API. A permission will be a combination of the service, the user, a measurement type and a read/write flag.

The data store could then be expanded to include:

• additional schema to support new types of measurements
• new data formats such as images and documents.
• localised versions of the datastores
• integration with additional NHS board systems

How to implement?

To prove the viability of the concept we recommend developing a prototype of the platform, working with a number of other NHS and third party developers of end user services. The platform would focus on delivering the following components:

• Authentication: Develop a light weight authentication model that developers can integrate quickly with two–factor authentication built in
• RESTful APIs: A set of RESTful APIs that control permissions and read/write access to the data
• Schemas: Meta data schema based on established standards and covering the range of measurements collected by the services

The key to generating value from the platform will be integrating services that meet end user needs.

There are a number of small pilots going on throughout Scotland that are collecting data from end users and attempting to share information from NHS systems with users. We recommend identifying five to ten services to be part of the platform prototype. The DHI is already funding many examples.

To get the platform prototype moving quickly we recommend developing the platform and associated data stores on the public cloud platform using the encryption technology available there. We believe the objectives of this platform prototype are in line with the objectives stated in the Scottish Government E-Health Strategy, Scotland’s Digital Future: A strategy for Scotland (PDF) and the recommendations from the Christie Commission.

And that a collaborative, user centred and agile approach to delivery using cloud, APIs and mobile will be key to the successful delivery.