THE IMPACT OF DIGITAL TRANSFORMATION ON PATIENT EXPERIENCE:
REFLECTIONS ON PATIENT-CENTERED CARE FROM AROUND THE WORLD

Authors : Taylor Johansen (Canada, Co-Chair), Emil Ackerman (Finland, Co-Chair),  Alison Curfman (United States), Cátia Ferreira (Portugal), Christy Lam (Hong Kong), Leandro Luis (Portugal). Reviewed by Tavy Alford (Intern  at the International Hospital Federation).

PREFACE

“One morning I decided to take my dog for a long hike along a trail in Nuuksio national park, not too far from my home in Southern Finland. Despite the beautiful views, it would prove to be an unlucky day for me; I lost my footing on one of the steepest inclines and, much to my dismay, broke my tibia. 24 hours later I found myself laid up on my sofa, full of pain killers and casted from the knee down. Seeing as it was the middle of the coronavirus pandemic, I was worried about what the coming weeks would entail and how I would stay safe while balancing my new care needs. But, as it turned out, the worldwide crisis was exactly what my healthcare system needed to inspire change. A couple of weeks into having the cast, I developed an irritating rash on my injured leg. But instead of hobbling to the clinic, waiting hours to be seen, obtaining a prescription on a cocktail napkin-sized piece of paper and limping to the nearest pharmacy only to wait again, all I did was snap a photo on my iPhone and send it to my remotely-working physician, alongside a few notes. A few hours later, she had diagnosed my issue, suggested a medication and had taken the liberty of sharing my prescription directly with my pharmacist, who prepared it immediately. I didn’t even have to pick it up, thanks to my pharmacy’s new home delivery service. And so, at a time when both my mobility and pain were at their worst, I am so grateful that the system that is in charge of caring for me did just that.”

– Story adapted from response to YEL2021 patient experience survey

INTRODUCTION

Despite the hard work of clinicians and health administrators around the world, healthcare systems are facing rising costs, varying quality, and higher case complexity. Consumers of healthcare are also demanding better experience when accessing care – especially as they encounter improvements in other industries that deliver a unique, pleasant digital experience. Healthcare as an industry must shift from supply-driven systems that are organised around what clinicians do and instead transition to patient-centered systems, organised around what patients need, prefer and value.

The concept of “value” was introduced in 2006 by Michael Porter and Elizabeth Teisberg in their book “Redefining Health Care”. They argued that patients need to be treated as full allies in their own care and co-designers of system-enhancing activities – a concept that some healthcare workers still find challenging. Understanding patient experience is integral to moving towards patient-centered care. Evidence suggests a positive correlation between good patient experience and important healthcare outcomes, such as patient engagement, adherence to medical advice, clinical outcomes, patient safety, and decreased redundancy in service utilization. Similarly, in systems where patients have a choice of which provider to interact with, patient experience has been shown to be directly related to clinical relationship longevity.

The COVID-19 pandemic was a major stress test on healthcare services on account of an enormous influx of questions from patients requiring immediate and critical health information. It forced hospitals to accelerate the adoption of digital health technologies (e.g. telehealth, telemonitoring, wearables, and apps); today technology is no longer just a functional tool, but a driver of patient experience, expanding capacities and extending boundaries of care.

A 2020 survey of 1500 adult patients in the US conducted by Forrester Consulting, showed that: i) more than a quarter of patients switched medical providers because of a poor digital health experience; ii) 65% of patients said they would leave a positive online review if the provider offered a great digital experience; and iii) The number of patients changing providers because of a poor digital experience increased by 40% from 2019.

This article presents both a summary of literature findings on the impact of digital transformation on patient experience, as well as an account of international patient perspectives, which were collected using a short descriptive survey in 2021. We argue that excellence in patient-centered care must involve digital technology; there’s no way back.

DIGITAL HEALTHCARE & PATIENT EXPERIENCE – A BRIEF LITERATURE REVIEW

We wanted to understand how digital transformation impacts patient-centeredness. Therefore, we conducted a literature search in PubMed, the New England Journal of Medicine, and the Journal of the American Medical Association databases. By searching the keywords “Digital Health” and “Patient-centered care” within the past five years, we found 233 eligible papers, of which 32 were given a detailed review.

Some studies showed that there are generational differences in the perception of digital solutions, particularly between those who are digital natives and those who are not.¹ According to the literature, the use of virtual tools like videoconference visits are largely appreciated among patients as long as virtual treatment is appropriate for their specific ailment. Reducing unnecessary travel time and expense is an element that patients appreciate particularly. A large study of over 5,000 virtual neurology visits reported this as a key outcome.² Studies on digital transformations implemented during COVID-19 lockdowns also found a high level of patient satisfaction, even though virtual care modalities were rapidly initiated.³ In fact, some research showed that patients felt their virtual care experience was “just as good as” or “better” than an in-person visit.⁴

Determining scientifically valid ways to measure patient experience is a challenge, but research has been done to identify tools and questionnaires with high rates of internal validity. ⁷

We found that digital healthcare and patient-centered care are deeply related concepts, and that, overarchingly, digital transformation improved access to care.  Most of the studies promoted the use of digital tools as a means to improve patient-centered care. ^8–30 Often, patients who engaged with digital healthcare programs also had better clinical outcomes, ^{8,13,20,30,31} such as better overall well-being,^19,27 better self-management,^8,19,20,28 improvement in patient-provider communication,^{15,17,19,21,28,29} improved medication adherence, reduced disease symptoms,²⁸ and reduction in travel time to appointments.¹⁵

Cautions about digital transformation raised in the literature included concerns about data uses,^10,16,32 privacy and regulation issues,^10,14 health inequalities,^16,26,27 lack of human contact,²⁷ and problems related to fear of change.¹⁶ One study showed that patients who accessed their radiology results via a portal expressed poorer understanding of their results than those who received their results via a conversation with their provider.⁵  Other studies found high patient satisfaction with telehealth visits, but still demonstrated that patients preferred in-person care.⁶  Often, the literature discussed issues related to adoption and management of digital transformations while facilitating patient-centered care. However, a key driver of success appears to be introducing digital health systems using a multi-tiered change management approach.²¹

Clinical leadership, reimbursement, licensure, liability, human factors, device interoperability and data integration, privacy and security, and performance measurement were also considered important to evaluate in relation to digital transformation and patient-centered care.

Overall, the literature boasted the positive impacts of digital transformation on patient-centeredness. Some studies even recommended making digital healthcare the first option for patients, and using in-person appointments only when digital care isn’t able to address the issue.^10,11,18,23 This attitude may mark a turning point for healthcare systems worldwide. Utilisation of digital health tools – proven effective in many countries – may indeed get us closer to achieving the third goal of the United Nations’ sustainable development framework: “Good Health and Well-being – Ensure healthy lives and promote well-being for all at all ages.”³³

RESULTS (INTERNATIONAL PATIENT PERSPECTIVES)

We wanted to understand feedback from real patients around the world about digital transformation as it relates to patient-centered care. We therefore conducted an anonymous survey featuring mostly open-ended questions and shared it across our networks; this resulted in 86 responses from five different regions (Canada, Finland, Germany, Hong Kong, and Portugal). We captured hundreds of quotes and this qualitative information was categorized into four themes:

1. 1. Perspectives on the effect of digital technology implementation in healthcare
   2. Evolution of the patient-provider relationship (amid digital transformation)
   3. Opinions on virtual care (e.g. telemedicine); and
   4. What makes healthcare technologies user-friendly

Patient perspectives on the effect of digital technology implementation in healthcare

Respondents indicated that there are many advantages and disadvantages of digital transformation in healthcare. Most often, respondents pointed out the advantages of easier access to information regarding their medical history, treatment plans, and appointment schedules. They also stated that the timeliness of access brought about psychological reassurance, which itself improved quality of life.

An often-mentioned advantage was improved communication between patients and healthcare personnel, resulting in better patient engagement. One respondent described it well: “I think digital technology provides a lot more options for providing care, getting in touch with healthcare professionals, and keeping track of appointments, tests, procedures, and results. I think digital technology has allowed the patient to be more knowledgeable on what is going on within their body and can collaborate with healthcare professionals in a more productive way.”

Another broad theme noted was the benefit of saving time, money, or other resources. For example, by attending virtual visits and virtual polyclinics, patients could avoid travel and call time, and could even renew prescriptions from the comfort of their own home. One respondent elaborated on her experience, “We live in a fairly rural area (about one hour to the hospital), so virtual appointments save me a lot of time (less work time lost) and money (gas, parking).”

Other advantages identified included the ability to access the best expertise (otherwise not available due to geographic limitations), the ability for healthcare professionals to make better decisions (e.g. with the use of data analytics), and improved opportunities for monitoring quality of care.

Some respondents cautioned that digital channels are not suitable for everyone. Reasons varied from patients’ lack of tech savviness to difficulty with access to web and IT tools. It was also mentioned that for a person with a hearing disability, it can be especially difficult to understand speech if you cannot fully see the speaker’s face.

An important point made was that regardless of its potential benefits, digital transformation can be implemented poorly, which can hinder healthcare quality. Implementation and change management problems were implicitly observed in some responses, which detailed examples of healthcare professionals failing to respond to messages sent through digital channels. This resulted in patient frustration and increased distrust of digital transformation as a whole.

Evolution of the patient-provider relationship

In general, digital technology was welcomed as a valid option for care, but perceptions of its effect on patient-provider relationships differed among respondents. Technology supporters felt digital platforms made them feel better cared for than traditional channels of care. In contrast, those with more negative attitudes stated that digital transformation could “forget people” and called for a return to face-to-face contact with professionals. Opposing views can be seen in the following quotes, which are both from respondents in Finland.

• • “There is an added feeling of safety when you have a channel through which you can ask anything at any time”
  • “Treating a patient would be better to happen in-person as it feels more humane and more trustworthy.”

The qualitative data we collected demonstrated that people feel emotionally connected to providers, as is often the goal in a therapeutic relationship. One respondent described the issue of evolving relationships in a moving way: “Nowadays you don’t meet a doctor or a nurse when things are taken care of by phone or digital platform. It makes me feel lonely.” Another patient described: “[Digital technology] improves my relationship with [my] healthcare providers as they can have a clear picture of my history before we start talking.”

Many other respondents felt that implementation of digital technology has not changed their relationship with healthcare staff at all. Overall, digital tools seemed to be accepted amongst respondents but there was no clear consensus on whether digital transformation has had a positive or negative impact on patient-provider relationships.

Opinions on virtual care

Many survey respondents welcomed virtual treatment options as a permanent service, due to its convenience, flexibility, and infection control. Examples of situations where virtual care was deemed appropriate included “minor, common illness”, “things that are not complicated” and “receiving group lectures on chronic illnesses”. One respondent stated, “For many simple things that need a doctor’s appointment – it’s been amazing to go virtual. Not having to find a babysitter, or wait with kids in a waiting room – so awesome.”

At the same time, the limitations of virtual care were recognised. A dermatology patient elaborated on this, “There are restrictions on actual physical touch to perform physical examination. For skin lesions, which rely on inspection to make the diagnosis, patients may need to adjust the camera to show the skin lesion properly to the doctor on virtual care. Some patients may require support from family / carers to do so.”

There were also patients who strongly preferred in-person care over virtual care, in general. “Interaction between humans is more than just voice and face. Wordless interaction cannot be transmitted through the web.”

What makes healthcare technologies user-friendly

Survey respondents described several characteristics that make healthcare technologies user-friendly and contribute to positive patient experiences. Recurring themes related to service quality included “easy to use”, “clear instructions”, “always accessible”, “at users’ own time and pace” and “quick response”.

One respondent observed a human touch in digital health technologies, “Even though you don’t see people in these platforms, there is a feeling that people care about you when you are being asked about your condition in between treatments. [There is a] feeling of personal and caring service even though [you are] using a digital tool.” Another respondent indicated their appreciation for “functions/channels to collect users’ feedback for continual improvement”.

Respondents also highlighted an affinity for clear and calm visual designs within digital platforms, and important technical aspects such as cyber security features.

DISCUSSION

As observed in our review of the literature, the introduction of digital technology into healthcare practice has impacted patients in a variety of ways. Some thrive in digital health environments, marvelling at its convenience, appreciating time saved, and demonstrating increased compliance with clinical recommendations. Others are disheartened by the shift or are pushed out of appropriate care because of inequities such as technological ineptitude or socioeconomic disadvantages. Across the board, studies have recorded administrative challenges including information security and privacy risks, and implementation change management difficulties – these, too, have impacted patient experience with digital transformation. Despite these challenges, overarchingly, written works to date suggest that digital transformation is supported and that digital healthcare has a positive impact on patient experience.

It is clear that the Covid-19 pandemic has pushed healthcare years ahead in digital adoption. When we asked patients for their opinions in 2021, most were in support of this evolution. Change champions described immense gratitude for decreased commuting while more circumspect respondents prudently cautioned the need to iron out technical issues, such as sound quality and user error (e.g. missed notifications). By and large, people connected digital adoption with patient-centeredness and therefore embraced continued forward momentum.

In our analysis, several interesting points surfaced. Firstly, in our small sample of 86 patient advisors from five regions, viewpoints were entirely consistent with the findings of the literature review. Indeed, even the volume of mentioned themes seemed congruent with the topics in published works. This suggests that the current body of knowledge is up-to-date with our collective networks’ experience.

Secondly, the qualitative data we collected was consistent across regions. Around the world, cultural nuances and geographic differences have the potential to significantly impact patient experience. Conceivably, survey responses would reflect different global expectations; however, within our sample, region of origin was almost indecipherable based on feelings alone. It can be assumed, therefore, that regions that are undertaking digital transformation in healthcare face similar issues – a true argument for worldwide collaboration.

Thirdly, the topic of financial cost of digital transformation was only briefly noted in the literature and went almost unmentioned in the patient experience survey. Despite the obvious requirement for financial investment in any digital transformation (both by institutions, for system implementation and by patients, for devices to access those systems), the lack of discussion about money is itself telling. We opt to assume that the value of pressing on with digital transformation, despite financial implications, is universally important. That is, that digital transformation has such potential to improve patient-centeredness, that patients’ wishes are simply paramount over obstacles like cost.

Finally, the theme of comparing digital interface with in-person human experience was raised by supporters and critics alike, in both the literature and survey data. As social beings, we rely on positive human connection and when accessing healthcare services, experiencing genuine empathy is crucial. We therefore question what the future holds as our global population ages. Today’s youngest generation has been born into a world that is rife with smart devices, remote monitoring, and artificial intelligence. Already, younger generations have demonstrated socialisation differences, such as preference for text communication over verbal conversation, use of emojis and memes to convey human emotions, and language reflective of their digitally-versed upbringing. These digital natives have a different set of expectations for person-to-person interaction and will undoubtedly demand that the healthcare industry deliver services that fit their social playbook. If patient experience feedback is the driver for the development of patient-centered care, then we believe the next generation will show us that the race toward digital transformation in healthcare has only just begun.

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