The essence of the Right ‘Healthcare at the Right Place’ is to prevent healthcare from becoming more expensive, moving healthcare closer to people’s homes and replacing healthcare by digital healthcare using e-health solutions. This improves people’s prospects of coping and functioning with their illness or disability. It is vital for different healthcare organisations to collaborate transparently and efficiently in order to accomplish this transition. To that end, Caresharing developed the cBoards platform, focusing on collaboration between healthcare professionals, informal care providers and patients based on so-called ‘boards’. A board is a theme-oriented, multidisciplinary patient file where all relevant medical details are accessible to relevant individuals and teams only. The healthcare professional experiences it as a single system, where things like chat and video communication with patients and other healthcare professionals take place. This makes (regional) collaboration safe, transparent and efficient. cBoards is now being successfully deployed in the Amsterdam region in collaboration with, among others, healthcare provider Zilveren Kruis and Sigra, a regional partnership between organisations in healthcare and well-being in and around Amsterdam.
Joining forces as a kick-off to scaling ‘cBoards, unless’
The healthcare landscape is changing: healthcare used to be organised quite linearly (e.g. from GP to specialist) in the past, but today it is based on a network of healthcare providers surrounding a healthcare consumer. However, as more healthcare providers are involved in the process, it becomes an increasingly difficult challenge to align between stakeholders and keep each other informed on relevant developments. The same applies to the Amsterdam region.
Late 2018, Sigra joined a regional discussion between various VVT [nursing, care and home care] institutions concerning transmural communication. There was a shared need to make alignment uniform and efficient, especially since analogue dossiers were being replaced by digital files. “To that end, the ‘Communicatie in de Wijk’ [Communication in the District] project was created. Following a problem analysis and a selection process, four pilots were kicked off with two different suppliers that could potentially meet this demand. cBoards came out on top when it comes to quick, incremental scaling”, according to Floor Bos, digital healthcare manager with Sigra. Early 2020, the assessment report on the scaling plans was presented. When the corona pandemic began, it was initially thought that scaling across the entire Amsterdam region could be financed by the Incentive Scheme for eHealth at Home (SET) subsidy, but things turned out differently. Bos: “In the beginning of the pandemic, available government subsidies for digital remote healthcare were mostly being used to facilitate video calling within healthcare organisations. Collaboration between different types of healthcare institutions is much more complex so that is not where the money was being spent.”
In order to establish an efficient collaboration platform in the Amsterdam region regardless, it was decided to join forces with two other regional digital healthcare projects. One is the Virtual Ward project, which aims to treat vulnerable patients at home instead of at the hospital, by digitally integrating hospital, first line and home care. The project is an initiative by OLVG and Cordaan in collaboration with the Amsterdamse Huisartsen Alliantie [Amsterdam GP’s Alliance] and Zilveren Kruis. “The ever-growing staff shortages in healthcare have been a point of concern for a while. But what made it especially urgent in Amsterdam was the fact that the OLVG West location gained a lot of patients due to the bankruptcy of MC Slotervaart in 2018”, Jan Christiaan Huijsman, strategic digital healthcare consultant with Zilveren Kruis explains. Following an extensive selection process, cBoards became the digital tool of choice in this project. Huijsman: “We established a digital healthcare focus group that explored the market, screened suppliers and developed a model allowing us to compare the propositions of various suppliers. In this independent model, we looked at the added value for patients and healthcare professionals and the total cost of ownership of the technology, among other things, in order to establish the value of the suppliers compared to one another. Our investigation found cBoards to be the most valuable, concrete and pragmatic solution. Plus, Caresharing had already developed a fully interoperable system.”
In addition, Amsterdam Vitaal & Gezond programme was already active in the region, aiming to ensure that everyone can lead a vibrant and healthy life in the future while having access to high-quality and affordable support and healthcare. The programme is a collaboration between the Amsterdam municipality, Cliëntenbelang Amsterdam, healthcare and well-being suppliers united in Sigra and healthcare insurer Zilveren Kruis. Driven by the creed of ‘doing less, better, together’, the principle of ‘cBoards, unless’ was embraced for the Amsterdam region to stimulate transmural collaboration between healthcare professionals. Bos: “It is undesirable for healthcare professionals in the region to use different services such as Siilo, Signal or WhatsApp, since such fragmentation gets in the way of quick and efficient communication. One would like for everyone to make their own decision in this regard. But that demands complete interoperability between different technologies, which is a long way off. For now, the most important thing was to create scale.”
A combined top-down and bottom-up scaling strategy
A combined top-down and bottom-up strategy was deployed to create support and accomplish scale. According to Tijs Rietjens, director at Caresharing, the administrative collaboration between healthcare institutions in Amsterdam, supported by Sigra as a Regional Partnership organisation, played an important role in sketching the dot on the horizon and formulating supported objectives. “Together with all of the stakeholders’ administrators, we managed to sketch the bigger picture for the region. It became clear that rather than thinking in terms of point solutions only, a sustainable platform solution was the way to go. It isn’t primarily about the technology, but rather about finding a scalable solution for the long term”, Rietjens clarifies. To ensure optimal collaboration between all stakeholders, the five-layer interoperability model by Nictiz1 and the common eye method for collaboration were deployed. According to Huijsman, it is vital to retain focus on a shared vision and ambition: “In the ‘traditional’ world, all parties would keep their cards close to their chest and the assumption prevailed that we, as a health insurer, were only driven by commercial objectives. In today’s world, where the transformation assignment is more relevant than ever due to, in part, increasing staff shortages and growing healthcare demand, we are now moving towards openly sharing data and knowledge to keep healthcare as high quality as possible. In that regard, we consider cBoards a magnificent example, sort of like a small Gallic village that braves the dominant suppliers.” At the same time, it was vital for cBoards to demonstrate its added value throughout the scaling process, with concrete cases in everyday practice. As such, confidence in the application grew among practitioners.
The ‘geriatric care board’ as a successful use case
cBoards is currently operational in several healthcare organisations in the Amsterdam region and responses remain enthusiastic. One of the places where cBoards is being used is within the Beter Oud Amsterdam programme, where the geriatric care board is being used in the first phase to help GP’s organisations and VVT institutions with efficient collaboration. All important data for multidisciplinary healthcare associated with vulnerable seniors is brought together within this board, allowing all stakeholders to collaborate efficiently. This sounds simple, but can be difficult in practice, Martin Kuper, Geriatric nurse practitioner and geriatric care coordinator with the Regional Organisation for GPs Amsterdam (ROHA) explains: “At first, it was difficult to get healthcare parties on board because the platform is only truly valuable once all geriatric care professionals are connected. It wasn’t until cBoards’ wider introduction in the district that everyone understood the benefits: clear, safe and above all efficient communication and data exchange between various types of healthcare organisations. I experienced in practice that it is better to scale up gradually, from simply using chat to adopting more extensive functionalities.’’
A great need for network care improvement has existed for some time, especially in geriatric care where different types of healthcare professionals as well as informal care providers tend to be involved in the care process of a patient. The district nursing segment is now very enthusiastic about the amount of patient information from GPs available to them in the geriatric care board from, despite the fact that the platform still has difficulty communicating with the information systems of the VVT institution at times. ‘’Integration of cBoards in GP practices is proceeding quite smoothly, but when it comes to VVT institutions it remains a matter of cutting and pasting to store all information properly. Eventually, the goal is to establish a platform that communicates smoothly with the systems of all healthcare providers. Caresharing and the ECD suppliers are working hard towards that goal’’, according to Kuper.
Important follow-up steps for the Amsterdam region
At the moment, there is a strong focus on strategic portfolio management and the formulation of a broad scaling-up plan. This will require the technology to be developed further based on specific needs in the region. On top of that, the added value of cBoards for the region is being mapped in order to formulate the (social) business case. To that end, the number of polyclinic visits and the degree of therapy compliance after adoption of cBoards is being analysed, among other things. ‘’Considering the large number of patients, one would guess that our system can offer major benefits. But it is important to generate the necessary proof’’, Rietjens explains. According to Bos, it is difficult to formulate a definitive business case for digital innovations such as cBoards because their net positive effect only manifests when the physical therapist, GP and pharmacist all get involved.
In order to scale cBoards further, we are looking at the Virtual Geriatric Ward project as a follow-up to Communication in the District, where cBoards could offer support in broadening network healthcare, e.g. by facilitating efficient communication between geriatric healthcare and GGZ [mental health] institutions. In addition, we are exploring the option of deploying district teams to interface between the social domain and healthcare. According to Rietjens, it is important to keep learning from past implementation and scaling processes continuously. “We are constantly receiving questions whether cBoards can help, both from large-scale programmes such as Babyconnect and local healthcare institutions. A lot of our local accomplishments can then serve as a blueprint for the regional deployment of cBoards.”
Interoperability, end-user involvement and chain-transcending funding as important preconditions for delivering on the ambition
The stakeholders have far-reaching ambitions. But when it comes to scaling cBoards nationally, several important preconditions remain to be achieved. “Structural funding for transmural network healthcare is very much needed but still missing. Without structural funds for this type of innovation, industry-transcending transformations cannot be achieved”, Huijsman admits. In addition to the fact that chain-transcending funding will have to be organised in the future, interoperability plays an important role as well, according to Rietjens. Initiatives such as MedMij, NUTS, LSP Ketenzorg and TWIIN add a great deal of value in this regard. Rietjens: “More often than not, IT suppliers have no choice but to service the healthcare landscape like a chameleon in order to be as interoperable as possible with the existing information systems of healthcare organisations, each of which need slightly different connections”. Bos also emphasises the importance of such initiatives in order to keep healthcare affordable and organisable, especially since healthcare is now moving towards network healthcare. Bos: “Successful implementation and scaling of technology demands resilience and tends to be a lot of hard work with gradual reward for all the effort.” An important lesson was to involve both the healthcare professional and the patient in the implementation process by letting them experience how the technology can truly help them. The patient needs to experience how the technology can improve their quality of life. And the healthcare professional needs to come to the understanding that proper digital facilities will help them in keeping the healthcare streams manageable both today and in the future.
It is the shared ambition of stakeholders to improve the connection between the social domain and the medical domain in order to provide citizens with better (preventive) care to dampen the growing healthcare demand. Huijsman adds: “This requires powerful, reliable and high-quality digital platforms for effective and efficient collaboration between transmural healthcare partners, patients and informal care providers”. The partnership formulates goals and results based on the quadruple aim in order to make the quality improvement in healthcare transparent. Bos: “In terms of IT, we should work towards a more transparent landscape with less tools and annoying firewalls adding to the complexity of healthcare.” Rietjens adds that well-organised, interoperable networks constitute an important pillar to demonstrate the practical value of cBoards. It is important to look at the funding of a technology according to the principle of value-driven healthcare, not just for heart failure or dementia separately, but rather in terms of funding entire healthcare networks. That is the only way for digital applications such as cBoards to demonstrate their true value in healthcare and contribute to the accomplishment of the right care in the right place.
