Tapping into the Potential of Digital Health

Tim Blake, the founder and managing director of Semantic Consulting, helps organizations grapple with digital change and digital disruption. And he talks with Daniel about the challenges and potential of digital healthcare – as well as what he learned as the chief information officer of the Tasmanian Health System, such as, “Sometimes problems can be far simpler than we think they are when you ask the communities that really genuinely own those problems.”

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Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Tim Blake:
My personal belief is that mobile devices give us a massive qualitative step change in the delivery of healthcare. I think we will look back and see that the mobile device was one of the biggest changes.

Dr. Daniel Kraft:
Welcome to Healthy Conversations, I'm Dr. Daniel Kraft. In today's healthy conversation, we're lucky to have with us Tim Blake, who's the founder and Managing Director of Semantic Consulting, helping organizations grapple with digital change and digital disruption. So I love your short tagline, "Leading digital change in healthcare." How do you define digital health or digital change in this new era?

Tim Blake:
Part of me feels that ultimately digital health will be successful when we no longer call it digital health, it's just health. But I feel the change component of digital health has been really under focused on, and there's a whole, I think, science that needs to emerge in that process of taking some of the great innovation and making it systemic across the health system. And I guess as my organization works to do that, we uncover a range of really big challenges, and I personally love and enjoy the work of that translational change. The technology, relatively speaking, is often the easy part.

Dr. Daniel Kraft:
We're speaking now in 2022, and we're, at least in the United States, still using fax machines, and I got my last cardiac study back on a DVD, and I don't even own a DVD player anymore. So it's not always about the technology, but how do we integrate it and evolve, which is often disruptive to the established players. So maybe just walk us a bit through your fascinating work history that drove you into this field interfacing technology and healthcare.

Tim Blake:
I have a Master's degree in computer science from Cambridge University in the UK. About 20 years ago, I moved out to Australia, consulted with some of the big four consultancy companies around technology in healthcare, and then 10 years ago took the brave move to start my own consulting firm focusing on the things which I was passionate about. Like many of us, I have my own personal stories of being a carer and a patient myself that were part of my motivation for taking my skills into that field.
Australia has a public health system which is run at the state level, so I was the Chief Information Officer of the Tasmanian Health System, which is a small state within Australia, has about half a million residents and it's IT and health technology infrastructure, running a team of about 150 people. So that was a very formative experience for me, one where I came away with more than my fair share of battle scars. I helped to write the National Digital Health strategy for Australia, and writing digital health strategies for organizations that support primary care physicians or general practitioners there, and how that crosses over into acute care, and how we can span some of those boundaries using digital health technologies. I guess the unique part of what I do, Daniel, is that I typically stay around for two or three years with an organization after writing a strategy and then help them implement. Being held accountable to the work that you've produced certainly sharpens the quality of what it is that you do produce.

Dr. Daniel Kraft:
Tasmania particularly, and it might be a small state, you've got a very broad geography there. What were lessons you've learned about the locality of where health happens?

Tim Blake:
Tasmania is really fascinating in its demographics, tends to be toward the lower socioeconomic end of people in Australia, and there's a fairly sizable indigenous population. Even sometimes if you go 10, 20 minutes outside of the two major cities, they're really just large towns, you reach places where people live, some of them have never been into the city. It's a level of experience of life that some of us who grow up who are middle class, white, educated, live in metropolitan areas, do not fully comprehend. And that was really formative to the way I think about health care delivery. How you begin to factor some of those things into digital health strategies is complex.
This might sound shocking to you, but about 50% of Tasmanians are deemed to be functionally illiterate. That doesn't mean they can't read and write. Their ability to do so is impacted in terms of everyday activities. Similarly, a large number of Tasmanians are health illiterate. So I guess the time they're really focused me very sharply on, how do we design interventions around those communities in ways that is meaningful to them?
Daniel, I was sitting, about 10 years ago now, in a room where we were developing what was then called eHealth Strategy for Australia, and I looked around and it was 90% white men in suits, and I just had this moment of realization that we don't even really fully comprehend the problems that we are solving here, let alone own the solutions. You need a high degree of diversity. Sometimes problems can be far simpler than we think they are when you ask the communities that really genuinely own those problems.

Dr. Daniel Kraft:
Thank you for sharing that. I often like to think about these digital tools and technologies need to interface with not just the social determinants of health, but the digital determinants of health. Do they even have access to regular internet, let alone high speed? There's still lots and lots of barriers. Here in America, 50% of rural areas don't have high speed internet, as one small example.

Tim Blake:
And interestingly, the form factor that the technology takes is incredibly important. One of the problems I see, technology first, as a startup based on the interests that they have and the skills that they have, and I spend a lot of time working with clients trying to get them to nail down, who is the cohort of people that you are really trying to address here? Many diseases, for example, correlate more with people at a lower point on the socioeconomic spectrum. In Tasmania, I met people who would go without meals to pay for their data plan, but those people wouldn't have broadband at home, they wouldn't have an iPad, they wouldn't have a desktop computer, and yet some technology interventions designed with a web portal in mind exactly for a form factor that the cohort they think they're targeting doesn't really have. Because we do it back to front, we actually determine the technology we want to use first sometimes. And a lot of my time is spent really trying to explain that to people and get them think very carefully. That's often led to a mobile first strategy, but beyond that, it's led to a lot of realization around user experience, so how can we use iconography and color instead of language so that we can really genuinely make things accessible to people who have deep functional literacy issues.

Dr. Daniel Kraft:
And there's that famous quote, "The future's already here, just not evenly distributed." I've been curating that under a website called Digital.Health, where we have 1,500-plus solutions, and the workflow, given that spot solutions often don't get adopted by the clinical teams, let alone individual patient wants five apps for five different conditions.

Tim Blake:
We've seen this proliferation of innovation, but often it's not integrated innovation, it's point solutions. We have a huge problem in healthcare with disparate data. That's not just a technical interoperability problem, at the end of the day, that becomes a clinical safety issue, it becomes a coordination of care issue, it becomes a continuity of care issue. So the last thing we need to be doing with innovation is making the healthcare data problem worse.
I see a lot of solutions. I think the best of those solutions are where the technology is part of what you might term a digitally enabled model of care. It goes beyond being a solution to thinking deeply about how you integrate into a clinical workflow. It considers issues of privacy, security, consent, medical and legal challenges that might arise from new modalities of care. Perhaps there's a mobile app component, that mobile app is just the face of the model of care to the patient or the clinician, but is not the full extent of that solution.

Dr. Daniel Kraft:
And one technology stack that I think is enabling all of this is HL7, seven and you're Secretary of the Board for HL7 Australia.

Tim Blake:
I was formerly the Secretary of the Board of HL7 Australia. We've seen the emergence particularly of a new standard called FHIR, F-H-I-R, Fast Healthcare Interoperability Resources. The primary author of the standard is Graham Grieve. Graham, I think, was a bit tired of standards that came from ivory towers where a bunch of health informaticians sat around for five years, and then issued an edict, "Here is the standard, thou shall go and implement it." FHIR was built around a consensus model that got people to the table really early on in the standards development process through what we call Connectathons, and has different vendors with early implementations of those FHIR standards sitting around the table, sending messages back and forth confirming that the standard works, or in some instances that it doesn't work. That process has occurred before a standard has been declared, something that is normative or ready to be implemented. It might sound subtle, but that has really enabled FHIR as a standard to be more effective. So fundamentally, interoperability is not just a technical problem, it's a human problem. It's a problem of the human condition, and that's arguably why it's been so difficult. And before the last four or five years when FHIR has made substantial progress, interoperability had really made very little progress.

Dr. Daniel Kraft:
Many of our world's best innovations are simple, sometimes based more in functional or practical understanding of actually human behavior, including in the digital realm. Can you describe your thoughts and work on intrinsic factors and motivation, and how they've come to affect your work and mission?

Tim Blake:
Part of the work I do is in the space of what you would call behavioral health. And to some people behavioral health is predominantly limited to mental health. There are studies that show that cognitive behavioral therapies can be delivered in digital forms, and still be pretty much as effective as the face equivalents. If you broaden out though from that limiting to mental health, behavioral health is about fundamentally changing the risk factors that lead to disease. And my personal belief is that mobile devices give us a massive qualitative step change in the delivery of healthcare.
I think we will look back and see that the mobile device was one of the biggest changes. It's not simply a device so much as we now have a one-to-one bidirectional communication channel with individual patients and health consumers. That isn't something we had 10 years ago, and we can really design new tailored interventions at the individual level, which is really exciting. Behavioral health then, whether that be via nudge theories or other ways, gamification is an early and simple example of modifying behavior, tapping into people's competitive nature in order to modify their behaviors. What we are learning in this emerging area of behavioral health is that there are a range of techniques available, often delivered via mobile, or it may be via wearable devices, watches, clothing, but the fundamental concept of this bidirectional conversation with the patient to modify behaviors and risk factors, it's just this really exciting new science.

Dr. Daniel Kraft:
Especially our bad behaviors drives I think 80% of our healthcare costs and morbidity. And so if you can get tuned into someone's intrinsic and extrinsic factors, you can leverage the right sort of sensor and or interface to help them, not just nudge to prevention, but even to manage their acute or chronic disease.

Tim Blake:
Some of those techniques of gamification, of competition, of extrinsic motivation, are effective for a period of time, depending on personality. But at a certain point, that motivation fails, and one of two things has typically happened. You've either converted your motivation to be an intrinsic motivation. It's the sense that, "I am a healthy person. I'm just going to do this. I don't need to compete with people anymore." Or you take the thing off and you leave it on your shelf.
And it's really interesting to compare with mature areas of behavioral health modification like smoking cessation, for example, where what changes fundamentally is people's beliefs about the world and about themselves. If you are successful in your cessation of smoking journey, you go from being, "I am a smoker," to, "I am a non-smoker." That's what fundamentally changes in you. What we need to do now is tap into some of the more sophisticated techniques other sectors have known how to use for some time, and away from the model that still predominates in healthcare, which is what is known as the information deficit model. This is the idea that you as a patient are a rational actor, and if only I provide you the information about the implications of your disease, then you'll suddenly start behaving differently. You won't be obese anymore, and you're now going to exercise. The world doesn't work like that. So we need to become more sophisticated, and digital is a wonderful channel to do that.

Dr. Daniel Kraft:
So we have a lot of health practitioners listening. I've often, when I meet fellow clinicians, asked them, "How many of you ever prescribed a Fitbit or any other kind of digital nudge type therapy to the patients who might need to exercise more and eat less?"

Tim Blake:
Look, there are some wonderful emerging tools, the platform that you are creating with Digital.Health. There's some wonderful work by guys like ORCHA in the UK, who have a library of curated digital therapeutics that can be recommended or prescribed to patients. I guess you could draw a comparison between a medication formulary and a digital health formulary, so tools where you can go and see what is indicated and contraindicated for particular conditions. "Now my patient has depression, what would be a good app or intervention or digital therapeutic for them to use?" And in fact, we've seen that, in Germany, start to emerge, where insurers are now paying for a number of proven interventions. I think digital therapeutics will be another tool in the arsenal alongside medications. And I'd certainly love to see a world where we expand the toolbox that clinicians have.

Dr. Daniel Kraft:
And the challenge often is, maybe I as your clinician would like to see how you're doing on your steps every day, or how many workouts you may have done to be proactive, but that often doesn't fit into the workflow of the clinician who doesn't really want to see that data, or doesn't even know what to do with it. Have you seen any smart evolution of that workflow piece, whether it's into the EMR or otherwise, that would help engage the clinician into that data on maybe, steps, of course, not the be all end all, more a way to even track someone after they've had a total hip replacement?

Tim Blake:
So I want to talk a little bit about some of the remote patient monitoring work that we've done in an area of Australia called Gippsland, and contrast with emerging platforms like the one we've been involved in. The early stage platforms are okay, they collect vital sign information off a bunch of wearable sensors that a patient may have in the home, but one of the challenges is they present that information, number one, in a separate system, but, number two, in a very raw form. I've seen large screens filled with traffic light colors for every single vital that a patient has reported every single day. Now we already have physicians who are burned out, and now we are producing screens with huge volumes of data that you can drown in. So some of the remote patient monitoring we've done with this platform, Lifeguard, in Gippsland, has been to prevent avoidable hospitalization when it comes to chronic disease.
One of the challenges we face in these rural areas is that patients with low health literacy, particularly men, to be frank, often let conditions get far worse than they should before seeing the doctor. And actually we have different modes where carers can enter data on their behalf. If the patient is within safe boundaries, nothing really happens. However, if a patient goes outside of what's deemed to be a clinically safe boundary, then both clinician and patient are alerted that something might be amiss and that a triage event needs to occur.
A lot of the work I've done is not so much in the platform, but actually working with groups of clinicians to say, "What are those thresholds? Where do we set the ratio here?" And moving beyond just a simple, "Now we have a blood pressure that's over 150 over a hundred, now the patient needs to see me," typically we want more sophisticated thresholds that say, "If you see a resting heart rate increase of 40% over the course of a week, that might be clinically significant." And again, it depends on the condition, it depends on the individual. We need a new generation of clinical software. We have to get away from this world where every integration and interoperability point has to be funneled through a single vendor who now has a pipeline of integration work that's 1,000 years long. But I'm encouraged by some of the innovative alternatives that are arising.

Dr. Daniel Kraft:
Viva la revolution. If you were to put your futures hat on, what might your hope be for, let's say, a decade out in terms of what's possible with the digital technology mesh?

Tim Blake:
This might surprise you as an answer, but my hopes are less to do the technology itself. I think we have enough really innovative technology to last us a lifetime. My concern is on the change side, and a lot of the work I've done is in starting to measure how we do some of that change. So trying to understand at a reasonably granular level, what does current maturity look like? What are some of the technologies that are in place, how are they being used? But then what are some of the attitudes and beliefs towards digital health and data that are potentially holding back more systemic change? And I guess it's strange to me that we haven't done more of this.
So we still have these big challenges when it comes to motivation and understanding of why we even do some of these things in the first place, and basic digital literacy challenges. For me, this is the big elephant in the room. I go into a lot of situations where we are implementing a new digitally enabled model of care, and the doctors will say to me, "We are really concerned about our patient's digital literacy." And inevitably, without fail, the patients are fine. And I have myriad examples of octogenarians who have complied with technology usage every single day for months. However, physicians and nurses are a real problem when it comes to their, A, motivation, and often, B, digital literacy. And we assume that just because physicians are bright people that they will necessarily be digitally literate. That's not always the case.
So I was fascinated in this, and went back to sit in some lectures at medical school. There was still this basic air of cynicism around technology, delegate this to the most junior person in the room, ignore this and get on with the real work of medicine. Until we change those attitudes back in med school, we're actually not going to see fundamental systemic adoption across the board. We'll see the digitally literate run off ahead and exacerbate this digital divide that we have today.

Dr. Daniel Kraft:
So you have a particular fascination at the intersection of primary and acute care. Where did that come from, and what findings could you share about both patient outcomes and physician training that would really motivate clinical audiences who are, as we've talked about, tech-averse or tech-illiterate to get up to speed?

Tim Blake:
A few of the concepts we've talked about come together in this question. So in one particular rural area of Australia called Gippsland, we've worked with a US organization, Lifeguard, to provide a remote patient monitoring solution, like I said, around chronic disease management. However, we have integrated that same technology platform into an acute context as well, that I think is reasonably unique around the world. Now remember, in Australia, these are not organizations that are owned by the same company. Some are state funded, some are federally funded, and we have not paid them any financial incentive to do this. So back to this idea of intrinsic and extrinsic motivation, I think we have begun to tap into the intrinsic motivation of wanting to deliver better care to a patient, wanting to be a leading physician, as a powerful means of getting people to adopt a common platform.
From the platform's perspective, you have multiple different health organizations that are not the same company, governed and funded differently, managing that same patient, which is incredibly powerful cooperation across the health system. It's beginning to flip the model of healthcare where we are seeing people based on a clinician's determination of who is at risk based on real genuine hospitalization risk factors, as opposed to where people who get seen are the people who shout the loudest, people who call the first, people who have the strongest advocates. And like I said, we've used no external financial incentives, we've just done this by tapping into intrinsic motivators.

Dr. Daniel Kraft:
That seems to be, as I like to summarize the future of digital health, that ability to collect the data, make sense of it, proactively, make it personalized, and bring care arguably anywhere with better outcomes, and lower costs.

Tim Blake:
I think we'll be able to become more predictive over time as well. I think we have to remember the role of symptoms and proms in being predictive. At the end of the day, asking the patient, "How bad is your pain?" is still a good clinical question. I'm not sure if you're familiar with the Patient Activation Measure, which is a standardized score for effectively how engaged a patient is in their own care. We had one particular patient in his 70s who initially was a PAM level one, within three months, having entered symptoms, vitals, and kept a journal, went up to level four on the PAM scale. So in three months we saw the 70-year-old person transform completely from somebody who was disinterested in their own care to somebody who was highly empowered. All that that person did was reflect daily on the things they were putting into their monitoring app.

Dr. Daniel Kraft:
And I think that reflects on my next question. What is social prescribing?

Tim Blake:
The idea is a simple one, that potentially we don't just want to prescribe medications. So in addition to, maybe instead of, but often in addition to any medical solution or medication option, we have the ability to prescribe psychosocial interventions, maybe you could be part of a community garden. And we're seeing some really interesting results in the UK where it's become a standard thing now to send people to their local park run.

Dr. Daniel Kraft:
And I think, even in Canada, they're now being reimbursed for prescribing nature in some forms. So many lessons to learn here in how we shift our digital and technology integration. Thank you, Tim, for sharing your deep expertise and thoughts with us here on Healthy Conversations.