Innovation for Medically Vulnerable Populations, Part 5: Insights and Scaling aka The Cure for Pilot-itis
This 5-part blog series is about designing evidence-based patient-facing digital health interventions for vulnerable populations that are efficacious, scalable, and cost-effective. Think it’s a tall order? IT IS! But it’s not impossible. We have some insights we’d love to share with you. These insights come from our combined 20 years of experience designing, testing, and disseminating effective digital health interventions in medically vulnerable populations.
If you want to start from the beginning, check out Part 1, Part 2, Part 3, and Part 4.
Congratulations!! You’ve completed a massive task by designing and testing your first digital health intervention! You’ve analyzed the data and found out that it works (or it kind of works, or pieces of it work). This is great! So, now what?
This is the hard part which many people forget about: getting from proof of concept to performing at scale.
Collate lessons learned
First thing’s first: Identifying the lessons that you learned is an essential first step to rounding out the innovation life cycle. Without learning, there is no innovation. There is only reinventing the wheel and wasting precious resources. We have more than enough waste to go around in healthcare (to the tune of nearly $1 TRILLION each year in the healthcare system). In order to maximize learning and ensure your innovation can be scaled up, here are a the major questions to consider:
- What do you need to do differently in order to scale?
- What resources — financial, material and/or human — do you need to keep this going?
- Which do you have already?
- Are there unintended benefits or consequences to your innovation?
- Who might you need to keep your innovation going?
These questions will help you understand clinical nuance, a concept that states that services differ in the clinical benefit produced based on the means and context of service delivery.
It’s important to ensure that all of your stakeholders have a hand in contributing lessons learned. If you followed our advice in Part 2, you should already know who these stakeholders are and have a relationship with them so you can learn what their opinions are. Don’t put this feedback off. Over time, memories may fade. Capture these insights when they are fresh so you get the most meaningful data. Even more importantly, you may want to identify strategies and methods of organization for your champions, those leaders who have the influence, expertise and resources to mobilize action.
Dignity Health recently published the results of a randomized controlled study that demonstrated how use of the Propeller Health Asthma Platform improved asthma control in the Journal of Allergy and Clinical Immunology: In Practice. Propeller Health uses sensors, mobile applications, and analytics to monitor real-time medication use as well as environmental factors, illuminating patterns of medication use and delivering notifications about patients with worsening asthma control.
One key learning that emerged from the study highlights why you should collect information about lessons learned as well as from the outcome of interest. Dr. Rajan Merchant, the principal study investigator and physician at Dignity Health’s Woodland Clinic Medical Group stated “The research demonstrates that the benefits of telehealth go beyond monitoring medication adherence, but can also identify patterns of risk and impairment. This additional information may allow more timely interventions and enhanced asthma management.”
Design operations for scale
It’s possible you tested your innovation in a bubble. Maybe you had to make considerable changes to workflows, or hired an extra person for a year in order to get your innovation tested. And it works, which is great! Now, your challenge is to figure out what happens when you pop the bubble. Will your existing staff be able to integrate the innovation into their workflow? Don’t be afraid to scale back your intervention in order to scale up. The only way to know if you have a real winner on your hands is to try to replicate of your initial results. By now, you know what you’d do differently if you could do it again. You’ve already invested a significant amount of time and resources, and now is not the time to let your innovation die!
Take it in stages
You don’t have to go from 10 people to 10,000 in one step. You can scale your innovation in stages, however many make sense for your time, budget, and organizational needs. The second time around, you don’t have to forge ahead alone. Try identifying complementary partners for larger-scale collaboration and advocacy building for continued research. One underutilized source of partnerships is the city, county and/or state departments of public health. Need help learning more about how you can work with the public health department? Take a look at this directory from the National Association for City and County Health Officials (NACCHO) for help finding your local contact.
You’ve innovated once already — don’t be afraid to innovate again! Try to think outside the box about ways to raise funding, organizational support, or buy-in for your next step. For example, you could give a presentation on the results for your organization and/or stakeholders, or you could even throw a party to celebrate your wins (people love parties). If your innovation depended on a wearable, for example, those can raise the cost of a program tenfold at scale. But don’t despair! You may not need to scrap it if your patients can’t afford them. Follow the example of Recycle Health, a program out of Tufts University that solicits unused activity trackers and donates them to people who can’t afford them.
Know your (legal) stuff
Trying to transition your innovation from the academic research world to the real world? Your best partner is likely your institution’s technology transfer office. They will have all of the necessary information about legal questions that you may have such as patent protection and ownership as well as information regarding commercialization options. Common options for commercialization include:
- Licensing: Awarding rights to commercialize an innovation to another entity
- Partnerships: Industry partnerships can provide the necessary financial resources as well as additional capabilities that support replication of initial successes while you retain ownership.
Once you have solidified your partner for replication, identify any additional outcomes that you need to assess aside from the outcome of interest. This includes evaluating the ability to deliver savings (e.g., time, effort, future cost of care). (Don’t forget about the $1 TRILLION in wasteful spending.) If your innovation does not provide savings, it simply isn’t innovative. Cost savings represent a necessary (though not sufficient) step toward giving your economic model the green light.
A truly sustainable economic model requires buy in from ALL key stakeholders, best represented by the resources that they choose to invest in scaling the innovation and integrating it into the health care system. To secure this buy in, identify and define value propositions for each stakeholder. Each one needs to have a satisfactory answer to the question “What’s in it for me?” even if that benefit emerges in the long-term future rather than short-term. (Ideally there would be at least one short-term benefit for all the stakeholders.) Check out the chart below for examples of value propositions for mHealth interventions in low- and middle-income countries.
Connect to the health care system and infrastructure
The last and probably most important lesson: don’t build more silos. Find ways to share your results and lessons learned. Odds are, you are not the only organization that has your problem or one that has developed a solution similar to yours. Share your data to encourage replication; don’t follow the advice in this widely panned NEJM editorial.
- Publish in open-source journals. Open-source or open access is not longer antithetical to academic rigor. The Lancet recently announced the launch of The Lancet Public Health, an online only, open access journal to improve health equity and social justice.
- Publish outside of academic outlets. You likely have many stakeholders who are not avid medical journal readers (ie. your patients and their caregivers). Publish your learning in white papers and blogs for lay people to read. Include the results in your company’s newsletter and your trade association’s communications!
- Present findings. Don’t forget that in-person gatherings can be powerful opportunities for robust discussion and education: community meetings, patient advocacy meetings, patient boards, community collaboratives (see above about how people love parties).
- Empower internal ambassadors. Enable all of your staff including nurses, case managers, pharmacists, etc. to share their experiences as well as the results of the intervention at professional development gatherings so they can educate others in their discipline.
- Engage with the federal government. The Centers for Medicare and Medicaid Services has allocated $5 billion for investment in improvements to Medicaid IT. Other agencies that provide funding and technical assistance for innovations in tech in the safety net include:
- The Office of the National Coordinator for Health IT
- Health Resources and Services Administration (HRSA)
- Agency for Healthcare Research and Quality (AHRQ)
Outside of potential funding, collaborating with these agencies will provide access to technical assistance as well as open up a dialogue about policies and guidelines that may be necessary to support scaling up your innovation. Last but certainly not least, collaboration with these agencies provides a forum to advocate for eventual reimbursement, the Holy Grail for most digital health innovations.
Can’t wait to move this conversation forward! Share your experiences, thoughts and questions on Twitter with the hashtag #safetynettech.
Erica Levine is the Programs Director at the Duke Global Digital Health Science Center. She has over 8 years of experience translating evidence-based behavior change interventions for delivery on various technology platforms (SMS, IVR, web). She was leveraging technology for health in medically vulnerable populations way before it was cool. She has worked on projects in rural North Carolina, Boston, and Beijing.
Vanessa Mason is the co-founder of P2Health, an incubator and fund focused on public health tech startups that are innovating population health and preventive health, including companies that aim to reduce or eliminate health disparities. She has over a decade of experience in healthcare innovation and consumer engagement in both the United States and developing countries. Her experience in global health has shaped the way that she sees the role of technology and design in health for vulnerable populations: innovate and integrate rather than break and disrupt.
