Jim Ritchie

April 8, 2021

What does 'Digital First' really mean in healthcare

Initially posted to Medium 18th July 2020

Digital First is a bold statement of intent in healthcare, but one that, counterintuitively, poses a risk to meaningful digital transformation of services.

In the NHS Long Term Plan, Digital First is used to describe providing remote consultations that "...allow for longer and richer face-to-face consultations with clinicians where patients want or need it". Whilst the principle of distributing resources based on need is valid, this description describes digital substitution at best e.g. a video call in place of an in person visit; and at worst paints digitally delivered care as being in some way less meaningful. Here the driver for digital change is to support the existing out-patient paradigm rather than to reimagine what could be.

Helping pressured services manage demand, whilst at the same time offering a more convenient service for patients clearly has merit, but will not change the form of outpatient care in the way that we need. Accepting and addressing issues such as this is essential to progress the conversation as to what digital transformation means in healthcare.

So... if Digital First doesn't simply mean an evolution of the way in which we currently operate services, how should we approach the question of what it does mean? To answer this we have to be able to articulate what digital transformation means and offers, and this is harder than it seems with varying definitions, all with different degrees of detail.

A sensible first step is defining how digital differs from traditional IT. This separation is essential in articulating what digital can offer and how organisations must adapt their thinking to realise these benefits. Here, output based definitions are helpful to frame what is delivered, rather than the steps taken to achieve this:

- IT delivers technical answers to business questions
- Digital enables business evolution driven by technical change

This distinction focusses the Digital First conversation around the process, cultural, product and experience changes that digital delivers when done properly. Aligning these drivers with patient and staff experiences of receiving or delivering care create a compelling narrative as to what opportunities and benefits digital transformation can create, and moves away from questions of direct financial value. Critically, however, digital cannot exist without effective IT!

Moving organisations into a Digital First way of thinking also means challenging established thinking as to how digital change should be delivered in healthcare. Traditional project structures with waterfall delivery are common in IT and help when managing the balance between scope, cost and time to delivery. However, Digital First delivery needs more agile methods where there is remit to solve the problems faced by staff and patients in an iterative manner. Healthcare is a complex adaptive system which reacts and adapts when elements of the system are altered. As such, addressing a problem can change the nature of the problem requiring cycles of learning, change and development to find the correct balance. Iterative change is not new in healthcare, where the principles of continuous improvement are often well embedded.  What is missing is the cognitive leap to see that successful digital change is enabled by similar principles.

So if digital changes the nature of the problem, requires iterative development, needs to be driven by users not requirements, and does not rest easily against the waterfall models of project delivery commonly seen in healthcare, how can it be planned for?

Here the first step is to focus on gaining a deep understanding of the problems to be solved, and the capability that the business needs to develop to solve them. By defining the capabilities needed, it becomes easier for staff to explain the value of change and therefore for the business to support them:

"If only I could do this then I'd be able to do deliver that for our patients"

Defining capabilities that must be created also allows teams to work build logic models that outline the change in 
- process
- technology
- resource
that are needed to deliver what is required. In doing this, the relationships between the components of the solution can be better understood, and some changes anticipated. In effect this creates a recursive logic model where the interactions between the resources and activities can be tracked back to understand how changing these may impact the other (and thus change the nature of the overall problem). This approach also enables the inputs to change to be weighted (helping define the minimum amount of technology needed to solve the problem), and also emphasises that digital change does not happen in isolation.

In summary to reach Digital First in a meaningful way, it is critical for CxIOs and other clinical leaders to begin to more effectively describe what digital is, to relate its effective delivery to established improvement methods, and work with their colleagues to describe the opportunities that digital change will bring. This is the springboard to reimagining rather than replacing services and the foundation to sustainable digital change in healthcare.