Twenty  years ago, if you needed to deal with your bank, you had to take time off work, stand in queues, and be served by whichever (probably poorly trained) staff member was there that day at your local branch.  Now, you might have a lifetime relationship with a bank through your computer/phone/ATM, and only end up seeing a person for major life events once a decade - and be well-served and satisfied. So why, if you need health services in 2022, do you still have to take time off work, stand in queues, and be served by whichever (possibly poorly trained) staff member is there that day at your local facility?  

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Of course, given that health involves a human body, health services are going to require more face-time than banking.  However, there is an enormous need to make health services dramatically more convenient, accessible and effective (and cost-effective) by building them around digital tools.  And yes, telemedicine is a step in the right direction, but that is like a bank claiming that it has digital services because you can book a call with a teller - it’s just not what we expect in 2022!

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Sorry for a touch of consultant-speak, but some terminology differentiating digitisation, digitalisation and digital transformation is helpful for understanding what it is that we DO expect from services. Health services are mostly through the digitisation stage (collecting digitised information on existing processes); and is in some cases like telemedicine, starting to embrace digitalization (using digital data and tools to improve delivery of existing services); but only now are folks in health starting to look at digital transformation (rolling out digitally-integrated health services that allow for new models of care via automation, self-service, etc).

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This digital transformation is essential to address the deep structural challenges in health (insufficient staff, runaway costs), but medicine and tech are two  big domains that don't always easily mix. My partner, Dr Abrahams, and I founded Aviro to help providers take that step towards digital transformation and, in that spirit, I wanted to share some lessons we’ve learnt in developing and scaling digitised self-screening services.

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For context, our focus at Aviro in the last 4 years was developing digitally supported HIV self-testing services in South Africa and Kenya (the Aviro Pocket Clinic) so that patient counselling, screening and linkages to services can be quickly and easily automated by health providers, enhancing care accessibility and delivery efficiency. We’re coming up soon on 100,000 patients served and we’ve learned a lot along the way, but I'll focus here on seven key lessons we’ve integrated into our solutions.  

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The patient experience is always the right place to start from with a service, so let’s jump in there:

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1 - Convenience is the main reason patients try a digitally-supported service 

Although there are lots of reasons why folks might use digitally-supported services, by far the #1 cited reason by users of Pocket Clinic in the feedback is always convenience - it’s just a faster and easier way to get screened. 

However, if the promise to the patient of a service is convenience, it is critical to not stop at the tech components: the whole experience has to demonstrate convenience by removing barriers throughout, all the way from the awareness materials through the clinical flows and the linkages to further services. It means making sure that multiple native languages are supported for patient ease, staff are trained for speed, the length/detail of the counselling is kept to the essential, the process is communicated in advance, the “data input” ask of patients is minimised, and so on.  Everything must first and foremost be geared to frictionlessness - getting folks to the right information and actions at the right time. 

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2 - Create trust, because health is sensitive 

But, of course, although fast and easy is essential, it also needs to meet minimum criteria. Even if the main motivator for self-screening is convenience, privacy (or the lack thereof) is a major concern to manage - and the right balance is not always obvious up front. For instance, we assumed early on that most folks would want to test for HIV at home with our automated support via phone.  A big learning for us was the importance of places to screen that are NOT in the home, which for many people is not a private place (with family, flatmates etc around). When we experimented with tablet-equipped booths so that people could test quickly and privately on their way home or at their convenience, we found that a much higher  percentage  of our users find that to be preferable. 

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Also, on trust-building, it’s worth pointing to the importance of establishing and broadcasting partnerships with trusted providers (for instance, the endorsements we’ve gotten from National and Provincial governments make a huge difference) and strong data protection, so that patients feel at ease and can embrace the experience.

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3 - Don’t forget to delight 

Convenience and trust will get folks to use your service, but will they use it  next time as well, or will they recommend it to someone else?  Maybe. But if the service is safe and easy AND it is also thoughtfully delivered and sparks joy (I’m not kidding), then they definitely will.

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We wanted to build a service that worked for patients and took the time to listen and find little wins and niceties to show that we listened. I have been consistently surprised over the last few years at how thrilled people have been by the small touches (a certificate that you’ve tested, a translation into a local language) and how that has driven uptake. We must not undervalue how people are excited by innovation, especially when it is clear that it has been made with them in mind as individuals with unique needs (which they unfortunately rarely feel in much service delivery).

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4 - Health services can’t work without health workers 

Although we can automate much of a service, making it more convenient and accessible for patients, health workers will ALWAYS be involved at some point  to verify quality and provide specialised care. We found that whenever we tried to bypass workers and engage directly with patients “to empower them to advocate for their own care,” it always smashed against the reality of health workers’ needs/protocols. We have learned that health providers must be involved when it comes to building trust and fostering uptake and linkage to care. They need to fully grasp the advantages of digital services for patients as well as for themselves . And these workers need tools (like materials, training, and patient management software) to make this process easy.  There is no way to scale without their support.

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5 - Payers need to easily and frequently see the impact of continuing a service  

In healthcare, it is rarely the patient or the provider who pays. To ensure that services can be maintained, therefore, it is essential to understand and prove, on an ongoing basis, that the service is creating value by improving efficiency and outcomes.  Digitally-supported services MUST be launched from day 1 with top-notch administrative and tracking systems that allow for real-time monitoring and impact tracking, in addition to feedback loops for the patient and the provider.  This is harder than it sounds, as it requires a lot of research and engaging with experts to understand key program indicators, health economics, and the scientific literature, and this needs to be translated into easy to read/use dashboards based on  proven frameworks, all linked to data collected on  a platform that can adjust and change to respond to patient needs over time. But when everyone can see the value of the service at any time, the payoff is huge in terms of buy-in and commitment .

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6 - Digital services take a LOT of time, resources, care and patience to get right

There is a lot of off-the-shelf software in the world now, so that a decent engineer can quickly customise and launch software in a few weeks.  This is great, but unfortunately also means that many providers are tempted into thinking that they can quickly just build their own digital services - and end up with a rude awakening. To actually build digital services that effectively serve users and drive positive outcomes requires extensive user research; building out great (and correct) medical content to support different patients in their language; defining implementation protocols and flows; training health workers; developing marketing and training materials; deep research into impact pathways and indicators for program monitoring; trialling to demonstrate impact in pilots/research; and then redoing all of that for scaling (nevermind ensuring that the systems can operate sustainably and flexibly once at scale). This is a journey of years and not every provider should need to go through it. With Pocket Clinic, we are now able to implement with health providers in 4 weeks everything they need to be able to offer a digitised self-screening service that supports patients. This kind of offering and support is essential for many providers to be able to embrace digital transformation, and more companies need to offer it.

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7 - Keep iterating 

We've learned a lot over the last few years and have a great, solid, proven system. But our last lesson is that there really is no substitute for iteration. There are still a ton of improvements identified by users, by research, by data and by our design team that I know will make Pocket Clinic better. And times are always changing.  Services need to continuously evolve,  adapt and improve, and we need to be constantly  testing ideas and rolling out those which work - ie improve the experience, outcomes and efficiency of services.  Fortunately, digitally-supported services are both easier to monitor/assess/troubleshoot and  also to roll out improvements on than traditional systems!

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Digital transformation is coming to health, and we’re really excited to be contributing as Aviro. The fundamentals of providing effective digitally-supported HIVST are now working and proven. We have demonstrated that our Pocket Clinic can significantly reduce the cost and time of screening, that providers can have our systems up and running and demonstrating value in less than 4 weeks, and that the patients we need to reach are enthusiastic about it. I hope that these lessons learned will help others as they also look to support digital transformation in healthcare.  Getting it right will mean millions more people will be able to obtain services without increasing budgets - and the world sorely needs it!

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Luke

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PS If you are interested in seeing Pocket Clinic in your programs, please reach out directly to me to see how we can work together.

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