In this presentation, Alison, the SVP of ORCHA, will delve into the dynamic realm of digital health and its integration into clinical practice. As technology continues to revolutionise healthcare, Alison will explore the myriad opportunities it presents, the inevitable challenges faced, and the essential requirements for successful integration.

Expert: Alison Johnson, Senior Vice President of UK Health Systems, ORCHA

Transcription:

Hello, everyone. I'm just, well, Molly brings the slides. up. I will start anyway by introducing myself and saying welcome to people as they join  and let you know it's all working fine apart from the slides, which I'm sure are on their way. My name's Helen Serrana. I'm one of the editors at BMJX and one of the people behind the whole future health  program that we're running, which includes these series of free webinars and the event in November, which you will.

hopefully have seen is now available to register for.  So the slides are working. I'm told, so that's great.  Are going to start, so I can't see the slides, but we'll move on to the I'm going to presume that you can see the slide which introduces our speaker, which is Alison Johnson from Orca.

She's the Senior Vice President of UK Health Systems. So welcome, Alison. Thank you so much for joining us. And we're delighted that Orca have been working with us on so much of the Future Health Programme and our Alison, I'm going to hand over to you to introduce yourself more and and this session.

Thank you.  

Thank you so much, Helen. And good evening, good evening, everyone. It's a delight to be with you all. My name's Alison Johnson. I'm the UK Health Lead with ORCA, which stands for the Organisation for the Review of Care and Health Apps. A little bit about me so I'm not going to say how many years in the NHS, but I've done considerable amount of years.

I can in the NHS across a number of roles in both operations and transformation and worked across many parts of their healthcare system, including primary care and in acute trusts as well. So I've worked a lot on supporting patients and families through pathways previously, and also working with clinical teams to get the best out of those pathways as well. 

More recently, my career has led me to Orca and I support UK health systems, and that's everything  from the work we do with our customer base in terms of the platforms, the libraries, and the formularies that we present to clients to make sure they're getting the best possible apps and products on there, right through to developing digital care pathways.

And so, really pleased to join you this evening. And I've got some slides that I'll talk through. I'll give a little bit of a product demonstration as well. And I understand there's going to be plenty of opportunity for questions as well. So just check in with Helen and Molly. If there's no other housekeeping, then I'll just jump straight into the presentation.

Yep. Please go ahead. And just to remind everyone that the chat section is open. So please, as you're going through, please do introduce yourselves to each other and put any questions in there. We'll be monitoring that.  Over to you, Alison. 

Thank you, Helen. And hopefully you can all see the slide deck that I am now sharing. 

So I've called this optimising digital care pathways at scale. scale insights and strategies, but in talking through the sessions this evening, I'm going to cover the following topics. So I'm going to  hopefully give you an introduction to the world of digital health and the opportunities that are available in working with people.

digital health. And from my perspective tonight, it's patient facing digital health that I'm going to be focusing on. I'm going to talk a little bit about the barriers to adoption, what they are and how we work through those barriers continuously to really activate the potential for patient facing digital health.

I'm going to talk about safety and evidence through evaluation and the different standards that are available and the frameworks that we support in doing that. And then I'm going to change tack slightly and move into clinical care and patient pathways and how we develop our pathways with the digital overlay. 

And then finally, I'm going to talk about activation strategies that we use with clients in different sectors within UK Health to really make sure that patient facing technologies are available to members of the population.  It's an augmentation to the treatment that they are already receiving.

So we don't see this as an instead of. It's very much an alignment with existing treatment pathways as part of a patient's condition. I want to talk about that a little bit as well.  So, I'm going to start just by talking about the digital opportunity and I've just put here this map with the top countries that really have capitalized on patient facing digital health technology, so, There's self care, self management, and use of apps as part of this, and we can see those spread out across the globe.

And that's basically we've seen that really explode since the pandemic in 2020. So over 6 billion people across the world now have access to a smartphone. That's more people than own a toothbrush. And that has enabled an opportunity for us to really share apps in a way that we've never been able to before.

So previously where we focused on web based solutions, we now have the opportunity for anybody who wants to interact with an app to be able to do so. And over 5 million people will download a health app every day.  So, 93 percent of clinicians believe that digital technologies then can help and support patient treatment and 65 year olds want to engage with digital health apps.

And I know from the work that I previously undertaken quite often the age is seen as a barrier that there's a perception that perhaps the over 65s won't potentially want to interact with an app, they won't feel as confident, and we absolutely know that that's not the case through a lot of the work and the research, the one poll research we've undertaken at Orca. 

So, before I get into this, I just want to explain Orca and the, the assurance that it has. space in which we work and from the work that we've done in the assurance space and oh, you know, the in the 20, 000 apps that we've assessed only 20 percent of those meet the quality thresholds that we would expect from working with an app.

There are over 365, 000 apps available globally. So this is the first challenge, is how do people or yourselves as clinicians or people working across healthcare systems actually know which ones are safe and effective to use that they'd be willing to share?  with members of the public. And I guess this is the whole point of the digital need really.

If we have the power to really revolutionize healthcare, then we have to be really responsible with it in just the same way we would with any other area of clinical practice. And I always use an analogy around medication, actually. Because from a trust perspective in the UK, we look to the MHRA as our licensing body for drug for drugs.

We know that NICE assess medications before they're offered out. And in digital health it's exactly the same. And I'll come on and explain what I mean by this shortly.  Awareness as clinicians, you'll have access to the BNF that enables you to look at interaction with drugs and people, look at the opportunities, look at the range of drugs that are available to people.

And in just the same way from a BNF that, that's almost like a single version of truth, if you like, from a UK perspective, we need to make sure the same exists for digital health.  Accessibility if you are having a GP consultation and you require a prescription, then there's an e system that enables you, the e prescribing system that enables you to receive that prescription safely and securely.

And then finally, the governance that, you know, the, if you think about the prescription programs through medication optimization you've got day takes for untoward events recording. Similarly, we need a system in digital health where that constant evaluation is taking place and with 365, 000 apps available then that becomes a bit of a wild west without those standards in place.

And there's a number of digital health frameworks that exist to enable this. And the main one that's in use across the UK is the DTAC and the ISO 823 04. So I'm gonna just start with trust and look at how we work across orca. But the starting point of the digital health assessment frameworks that are in place.

So in the NHS as I've just described, we've got the dtac, the Digital Technology Assessment Criteria which means that any patient facing in technology. That a developer would wish to use or an NHS organization would wish to have as part of his  services needs to have a DTAC certificate.  There's the ISO 82304 and 2 around clinical safety standards.

We've got the DIGA in Germany. And we've got the Nordic across the five Nordic countries. We've got the USA DHEF, and then in Canada, we've got the Mental Health Commission of Canada. And each of these either national bodies or countries have come together to determine the digital health framework that's going to work for them and aligned with another, a number of key things that we'd expect to see. 

So there's a lot of convergence across those assessment frameworks. And if we look at the bright pink line at the bottom, the global baseline review, this is the ORCA accreditation. So this is the work that ORCA does and the areas of focus that we look at. We provide support in what we call the Orca Baseline Review, and then we review against every single one of these different frameworks.

So you can see from the Global Baseline Review, the Orca Baseline Review, the top thing for us in terms of app assessment assurance is around clinical assurance. That we're wanting to make sure that any product that's featured on one of our libraries or our formulary. actually meets the quality thresholds you'd expect and as part of that we're looking for a clinical assurance.

So whether that's an app that's been developed by a group of clinicians or has got evidence around research and efficacy in terms of the claims that the app has been is making  in how it supports health and being, we're looking for evidence of that in our assessment process.  The second thing we're looking at is usability and accessibility, so making sure That the app is easy to use and safe to use and from an accessibility perspective gives people options.

So it covers everything that you would expect to see in an, in accessibility guidance and then  data and privacy. So the security of information that's held within the app is really important to us.  So in terms of working across the clinical the national bodies, we've worked with each of these national bodies to actually help them develop.

And so from an NHS perspective for the UK audience, then the NHS DTAC covers clinical safety, technical stability, security, and enhanced data analysis.  So if we're undertaking an assessment of a product, we start with the global baseline review.  So we will make sure that we're meeting the assurance, usability, and data privacy, and then we will build an enhanced layer for the NHS DTAC, where we look in more detail at the clinical safety, technical stability, security, and enhanced data analysis. 

For the U. S. as an example, we'd look at our baseline review and then we'd be looking at user experience, security, and technical stability. And so you can see in those blue blocks where the different national bodies, what's important to them, what they're looking for through their national assessment framework, and how we support each of those.

And in fact, probably been instrumental in the development of a number of these working with those government bodies to make sure that assurance is safe.  So I want to talk a little bit about the OBR the Orca Baseline Review, and I've talked about the three areas and how we use So we have a 350 assessment criteria questionnaire that we work with any new developer or innovator around to make sure that their products are safe.

And what we're looking for is compliance with GDPR. As part of the data and privacy that there is a privacy policy in place that reflects how the data is going to be stored and used, and it has to meet the ISO 27, 001 standards from a professional assurance perspective, we're looking at medical device status and conformity.

So for those are for those apps. probably at a higher level, a three or a four level where they actually align with a medical device to support a clinical condition. We're looking at evidence and effectiveness, and we're looking at nice evidence standards frameworks as well. So we're aligned with nice standards to make sure  that any product that's being used from a professional perspective is safe.

And that it has had clinical involvement in its development. And then for usability and accessibility, we work with the guidance provided by Apple in terms of iOS and Android and the WCAGs, the ISO and bulk management. So we're taking all of this into account in the assurance that we provide of every single app. 

Orca have assured and assessed over 27, 000 products and our review engine is actually on its seventh iteration at the minute so that we're constantly reviewing, making sure that the questions are still relevant, that they're aligned with assessment frameworks And looking at, the kind of iteration we're currently going through at the minute, our next development is really focused from an AI perspective as well and the areas of focus within that. 

So DTAC is the main assessment framework that's used across the NHS and so any product that's used within the NHS  or is to be commissioned will need a DTAC assessment and we offer DTAC assessment. We're not the only company that that provide that, but we do offer this as a service and it covers clinical safety, data protection, technical assurance, and interoperability. 

And these are really key if we think about electronic health records these days and their use and their coverage, then it's making sure that every product has that interoperability so that it can be used as part of that EHR  framework.  For a product to pass the DTAC, it has to pass every single element of that from a safety perspective.

And it's in a continuous evaluation, so it's not something that you go through once and you pass and therefore you're DTAC compliant. It is an annual process as your product develops.  And I guess in just the same way that your phone probably goes through a regular update in terms of software, we're looking for this as well in the assessment of patient facing digital health technologies.

And so as part of the work that we do at Orca, because we're constantly re evaluating  the safety, If a product hasn't been upgraded in 18 months since it was first published, if indeed it passed the assessment, then we'll remove it from the library. So we're constantly reviewing and making sure that each of the products that are in the library that ever passed that quality threshold remains so. From a DTAC perspective you will see here that we also have cyber essentials, that any digital products that's used across the NHS or in UK health has to pass cyber essentials and is compliant with SOC 2 and the ISO criteria that I mentioned earlier. And I guess the way to look at this is it, whilst there are similarities across the standards it's an essential, it's not reinventing the wheel, but it's asking for information in a slightly different way. 

But that's really important.  So that those standards, are reflected across all sorts of different countries. And it's important from a developer perspective, if someone's developing a product or is, It's innovating that they understand each of those variations in the countries if they're hoping to introduce something that has global reach. 

I mentioned NICE earlier and NICE accreditation is expected alongside DTAC, so it's not one or the other, it is both and they're just some examples that we've put up here around how patient facing digital technology is being used to treat patients. We've seen aspects around WISA we saw Sleepio a couple of years ago that have been NICE accredited from a sleep hygiene perspective.

So NICE are now starting to encourage more accreditation in this area. Space as well and making recommendations of patient facing digital. Which is absolutely a great move a great step in the direction of how this can support patients. That said we're certainly not a kind of a tipping point as yet with this.

And it's something that we would like to see more of funding challenges.  Um, in terms of how we are supporting patient facing technology just alongside of the treatment elements.  So I talked a little bit about assurance and I now want to move into What we do with the product.

We have a library of over 3000 products from across whole swathe of clinical condition areas. And I guess it's what happens to these. How do we get these into the hands of patients?  So I guess the first thing I'm going to talk about are the opportunities for patient facing digital.

And one of the questions I'm asked a lot is what should the OneApp be that I, what's the OneApp I should be using? And we wouldn't recommend OneApp that we will always recommend a portfolio approach for patients. No, what works for one patient won't necessarily work for another.

And I guess if we go back and use the.  medication analogy, again, that's exactly true there too. So we will always recommend a portfolio of products. So if we just look at this opportunity of a 58 year old male with COPD.  So if we look at it from a prevention perspective, then is there anything we can do around smoking cessation?

So we've great uptake around activation with smoking cessation actually with a range of products that are available through the library. But also what can we do around environmental monitoring? How can we support people to really manage their condition? What we can do, what can we do around medication management support?

And then if we get into diagnosis. diagnostics then what are the technologies around remote assessment that could really help this gentlemen, how can we really support around patient education and what's the symptom tracking opportunities that exist, and then if on discharge from treatment than perhaps Think about pulmonary rehab quite often done face to face, but there are many opportunities where that can be done remotely too.

Again, thinking about medication management from an ongoing perspective and then inhaler technique. And this one's very personal to me cause I'm an asthma sufferer and I've been using my inhaler significantly at the weekend. I use an app. on a daily basis so I can manage my condition. I know if I've got an exacerbation I can record it and I actually use that information and data when I'm having an asthma review at my GP practice so I can share the app and I can share the data with them so they can see if I've had an exacerbation and a spike.

So this one's quite close to home for me and  it's really easy just to input it into an app on a daily basis. From a slightly different perspective, let's think about elective care and let's think about a 75 year old lady waiting for a hip replacement, that from an optimisation opportunity prior to surgery, we might want to consider weight loss, we might want to consider some exercise regime if it's appropriate, just to try and keep someone mobile, digital health coaching and pain management.

And then thinking about streamlining that care. And again, we've seen a lot of change post pandemic, post COVID, but what are the opportunities for remote pre op assessment? There's some fantastic tools that actually really capture that pre op assessment. element where it's not required from a face to face in a relatively healthy individual.

Again, patient education, how can we be really supporting people whilst they're waiting for surgery? And what's the remote monitoring that could take place there?  And then again, on discharge, how can we support rehabilitation post surgery? treatment? What are the medication management opportunities and what are the care coordination opportunities?

So I guess within this, it's just giving an opportunity that there's not just one app that would work for a patient in this area. We're looking at a portfolio effect of a number of apps that can be used over a lifespan. For a specific condition area.  And once we've understood that, we create what we call our pathway and we do this through a series of actions.

So our starting point is understanding a use case. We always work with the use case first. What are the problems that we're trying to address and which are the pain points which would actually link to a step within that pathway?  And we then look at the actual clinical pathway that's established across the local system.

And we look at the opportunities where a health app may alleviate some of those pain points. So we're not going in with a kind of overlay that's quite generic in nature. We're working very much with healthcare systems to understand what's important for them  at that particular point in time. What are the pain points and how can they be addressed?

And once we've got that, our clinical teams then start to draw up a long list of apps. So they'll start to create based on those pain points and the opportunities that present as part of those pain points, where the health apps could, that could really help solve a particular pain point.  And so you can see here an example of children and young people mental health pathway, and we've just got a couple of examples in the diagram where we've created the, we've mapped out the pain point we've mapped out the steps in the pathway and we're starting to identify some of those apps that could really support young people at that particular point, whether it was managing stress or whether it's management of self harm. 

at points of crisis. I'm also aware that quite recently I think it was in the first webinar in this series that you started to talk about pain points and started to talk about some of the problems and identifying those problems. And I guess there's a real sense that we kickstart our pathways and that we're doing a similar thing.

If this spikes interest for anyone as part of this webinar today, I'd say that, that call to action, think about those problems that you're trying to address. Yeah, just put that in as a bit of a call to action for you there.  So this is an example of a full pathway that was developed with Cheshire and Merseyside Integrated Care Board.

They identified heart failure as a particular area for them. They were doing some work to map out the whole patient pathway across the system and the different interdependencies and the pain points. I guess with this example of a pathway, It very much started by working with patients and clinicians and understanding from them what their experiences were what was working well, what wasn't working that well that we could really start to address so we could identify the opportunities for patient facing from the outset from both perspectives.

And this has been used Within the formulary, which is the space that we enable the recommendation of apps. So it's offering up an opportunity to really improve experience and outcomes. And so we can see at the very top. We've got prevention and we've got a range of apps to the right hand side of the page where. 

We know that they can make a difference around prevention. So whether that's around smoking cessation or whether that's, on a new diagnosis of heart failure, working with CV medical that provides advice and guidance and support to patients. And you will see through this this pathway the, the areas in pink are the pain points.

So how can we avoid repeat acute attendance through better through prevention and initial sign and symptoms and some of the apps that can support that. How can we support acute decompensation as we move down? So getting to some more of that self management with a range of apps mental health support for patients. Whether that's upon diagnosis and that feeling of stress and anxiety that can sometimes occur,  and then how we work with apps that when patients are stable, that's just as important as when patients may feel they're in crisis, that how do we actually stabilize. So this is a very much around.

come from that ethos of self care, self management additional support in between appointments or as part of the overall treatment.  And we work right through, so we've got apps in here that will support carers and family members equally as well as the patient. And we've mapped this through right through to end of life support.

This is an example of a pathway that is in place and is being used within across an ICB area by the heart failure team and I can give a very quick demonstration how we do that.  Once we've developed that pathway, we then deploy it across the healthcare systems and we do that three routes, education, distribution, and activation.

And so we've got a number of platforms that we use within Orca that I'll come on to in a second. But from a governance perspective it's coming back to that  what's the market opportunity, what's the intelligence what are we trying to do to address that pain point.

Accessibility through either a formulary from a, we're working with clients that have a formulary that provides that opportunity for healthcare and care professionals to know that they're recommending apps from a safe place. We've actually got a digital health academy which ensures that all frontline staff have access to online learning around patient based and digital health.

And that's available through Orca, but also available through Health Education England. Website as well for any clinician to interact with and that's all CPD accredited and then making sure that trust is in place either through DTAC or ISO or against a national framework as I described previously to you. 

So I guess before I move into the kind of libraries, just to bring this all together, the first point of this, of the Assure process, which is our assessment process, is making sure that we're assessing apps that meet that quality threshold that we will then publish on our library.  What we then do is run a scrape on a weekly basis that is looking for any change whether that's through an update but that will actually flag any app that requires a re review and that, that process runs on a weekly basis.

So we're always ahead of the curve and we've got really strong SLAs in place. To make sure that we are reassessing apps as, as soon as an upgrade is in place so we can capture any changes. That's really important because we don't want to change if a score of an app changes in terms of that threshold, we want to be on top of it and available to inform our clients.

The accreditation so we've talked about that which we've got different ways of accrediting and working with suppliers but the accreditation linked to the DTAC is important. And then the activation strategy for me this is the space that I'm very much a part of is Working with clinical teams to make sure that we're building out digital care pathways, but we're also creating environments from which apps can be recommended safely.

And  our compliance portal is part of that as well. So  making sure that clinical safety reports are accessible, that the evidence is available to people that need to see that regularly. And then from that building out our insights. So we've done a lot of research in this space. We also run one poll data on an annual basis that keeps us up to date with how the population want to use patient facing digital.

So making sure that digital transformation and those opportunities for research are available. And Spread as widely as we can.  So I'm just going to switch my screen just very quickly. So just bear with me one second. 

So again, hopefully you can all see my screen. So this is an example of a patient facing library. So we work with many NHS organizations and we offer two products. And the first is a patient facing library. So this is where our patients can come and self serve themselves. They can enter a search term here  and look for an app themselves.

And then we've got a series of carousels here. Where patients we can direct patients through specific campaigns into a range of curated apps that will suit their needs. So I'm just going to go into the waiting well. So this is work that we've been doing in the space of elective care and as part of supporting patients while they're waiting for treatment.

And we can see here a range of apps that have been curated.  just to support patients while they're waiting. So something that, we've got mental health support, we've got pain management, we've got sleep hygiene, we've got exercise and these are put together by our clinical leads. And then we produce this campaign so that We can share this out directly with members of the public but I wanted to share this with you because this is our formulary.

As clinicians, this is the space that our healthcare professionals could come to. Again, they can search for an app in just the same way as a patient can.  on the formulary and it will bring up the apps that are on our library around a specific area  and their score. So I've talked a lot about the  kind of score that we give to an app through our assessment and we only publish apps that score over 65  percent and over  and then we're constantly reviewing against that particular app. 

And I'm going to just click into  this app here, and it will give me a digital health passport. Just to show you an app card and the assessment, so this particular app gives us, it gives us a description, it tells us who the app is applicable for, so this one is applicable for adults and children over the age of 13, and it tells us how this app works.

can be used. So it can be used to track symptoms, medication. And then down here I get to see a score. I've talked about the Orca Baseline Review and the fact that we're tracking data and security, professional assurance and usability. And so we can see a combined score of 88 percent for this particular app. I'm just Move  back. If as a clinician I decided I wanted to recommend this app to a patient. I just click on this button here and it will ask me to enter the patient's name and either their mobile number or an email address, and from which the patient would then receive that particular app.

So there's a record that's kept of the app recommendation. And the patient knows that it's coming from the organization where that clinician is working. I just also wanted to show you, we talked about pathways a lot, and this is the range of pathways that we've currently got. So we've got pathways around back pain as part of our MSK  work COPD we've got depression and anxiety, we've got an elective care pathway.

Heart failure, which I've actually demonstrated to you and diabetes. So we've got a range of pathways here. We're constantly looking  to review those pathways and add to them. I'd also talked about the Academy, and you can access the Academy through the formulary as well so that bite size learning is available to people through the formulary as well.

And the.  opportunity to access those courses. So I just wanted to show you the platforms to help bring it to life a little bit if you like and I'll just go back into my slide deck. and where I was up to. Hopefully that has helped to bring it to life in terms of the platforms and how they are used by the clinicians and patients that we're working with.

I guess just some final thoughts that  The products within the Orca library are only as good as the developers and innovators that work to establish these great innovative products. And so we're constantly working with suppliers to support them as well. And to if they want advice on how to gain access to DTAC or for global prominence intelligence gathering.

So our team of assessors.  are constantly working with suppliers as well. So we recognize that they really are absolutely the foundations to all of the libraries and the activation strategies that we put in place. And just to share a couple of some results with you before I finish and then allow time for questions.

So we, we ran a winter pressures campaign that ran between November and February. And we saw over 12, 000 session hits in that. So we know there is an appetite in this space. Again we focused on respiratory and mental health. We provided paediatric supply advice for parents and access to vaccinations as well in line with the NHS vaccination program running at that time.

And so again, we saw significant uptake with respiratory and move food, which is actually an app for working with frail patients and managing falls. That was really interesting to see the kind of impact from those different areas and groups.  We've also been working with MIND, the National Mental Health Charity, and we've seen significant uptake through their library as well around mental health.

Mental health remains  the  highest searched term across every  client library, and I guess we know  In terms of the waiting list numbers and increase pressure on services at the minute. Again, for ourselves, it's about what are the apps that are really safe that can provide additional support to patients whilst they may be waiting  for treatment.

Again, just to share some stats with you there around downloads of apps in that space. So that is me bringing the kind of presentation to a close and just to reiterate it, it is about efficiencies through looking at where patient facing technology can be consistently applied as a, as an enabler.

from a self care and prevention perspective. It is about driving engagement and activation through education and training with the likes of the academy and the formulary. And it is about providing that infrastructure, not dissimilar to the prescription infrastructure that already exists so that we don't have a Wild West of products around digital health, but that we are all  confident in the assessment process that sits behind those.  Linking reimbursement to compliance is something that we're really keen to do, where healthcare systems are looking to  maybe commission  products on a block basis for as many members of the population as they can, as we're providing support in that space.

So that's a product development that's coming later in the year for us in that  space.  Hopefully that's been helpful. I'd be delighted to take any questions.  

Thank you so much, Alison. That's been brilliant. Really, a really helpful overview of what Orca does and how it supports the healthcare system.

We have got a couple of questions in already. The first is, Quite straightforward, but might broaden out a bit, which is  what, is there a strong rationale between the 18 for the 18 month threshold for an app to be able to be live on the site? Is there a good reason for that? And a sort of sub question, which Got me thinking, which is longevity or ongoing support or exit part of the assessment of whether an app is part, can be approved?

Cause obviously there's an issue with short term companies setting up one app, which has one version and then leaving. patients potentially high and dry. 

Yeah. And yeah, thank you so much for that question. It's really interesting. So I think 18 months is almost the, that's the hard start.

We'd be looking for upgrades much sooner than that. So if we've not had anything and we do reach out. So I think Helen, that picks up both points, really. I think during COVID and the pandemic, we saw an explosion of new app health and wellbeing apps coming onto the market that were. Probably produced to resolve a kind of an immediate problem, but then the resource wasn't put into maintaining that.

And that's where we're then sifting those out of the library. We will reach out to developers a number of times if we've not seen any upgrade or any change to that app. And then at 18 months, it's no, That it needs to be removed now because we just cannot  hold on to that assurance. So we're constantly, because that scrape is taking place on a constant basis, where we are monitoring for any change at all in that time period.

But it just gives us that ability to then say we can reach out and then we'll remove it.  But we hold on to that safety element in that time period. 

Yeah. Oh, thank you. That's really interesting. There's another question, which again is, could be taken quite broadly or quite narrowly, which is how do you differentiate whether the technology is patient facing or healthcare professions facing? 

And I'm guessing the answer is that increasingly there are some, there are products that are for both and with monitoring  the health profession. end might be of one standard and the patient end of another. How would you deal with that really important interface? Cause often that's what the apps are for, isn't it?

Yeah, we can, we break it down into three areas. So we break it down into almost like admin tools that so if we think about a number of apps that provide support around scheduling of appointments. That would be almost like an admin type tool. We then have clinical education which I guess is that process that it's very much aimed at the healthcare professional.

And so we're looking for the evidence then it's still have, it still needs to have had clinical involvement in it, but we're looking at a different range of evidence and actually within the heart failure pathway slide that I showed you. There was an app within that was developed by clinicians to navigate the heart failure pathway.

And so that app was assessed met the quality threshold and is now part of that pathway. So we're differentiating between tools that are supporting clinicians from an education perspective, but tools that are patient facing. We, whenever we're running a campaign We will then look and make sure that actually we're focused just on those very much those patient facing technologies and we tend to look at the level of the app that as part of that.

So we rate apps on a level of one to four.  So Level 1 would be like a well being type app. Many of us probably use Strava for measuring either walking or running, etc. That would be a Level 1 app. It's a well being app. You're capturing the data yourselves. It's not being shared unless you choose to share it with a fellow member, but it's not being used to create a diagnosis. 

A level two app would be a general health and being app and we work them right through to level four, which may have a medical device associated with it. So some of our diabetic glucose tracker type apps or cardiology type apps might have a device associated with them. or where there's a flow back of data would be a level four app.

So we're looking at all of those elements and the assessment process takes that into account.  

All right. Just got another question here from Maria Lopez, who's asking how does the digital transformation work interacting between patients and medical professionals on daily basis considering the limitations the NHS is confronting now in terms of various resources.

It's a real pressure point and how can you, suppose it's their consideration about how,  this, how applicable how usable and manageable to set up and help the patient. 

Very much so we actually have our customer success team will actually work with clinicians at the outset.

So we'll bring, we will work with clinicians. We try and keep meeting time down to a minimum because we understand how busy people are. But we will work with the clinical team to understand if they're using any apps already. So if they're using apps already we want them surfaced, so we want to know if they are safe, if they're already, if they're already on the library, then that's brilliant.

If not, we can assess those products and see if they are safe to be used. And we'll create very quickly with clinical teams a map. So we understand the workflow that clinicians are working to on a daily basis in a given environment. It's not always suitable to recommend an app in the middle of a ward round at the busiest time of day, then we'd say no but there will always be support staff where we are able to support and recommend.

So we've got one client. Who from an outpatient perspective the clinician will say they've got a short set of apps that they work with and the clinician will make that recommendation. And then it's a member of the admin team that will send out that recommendation. So that's just one example, but we work to understand what are the pain points and what's the clinical workflow.

So where does it make where's the best opportunity for that recommendation to take place both from the clinician that's making it and for the patient receiving it. But that's also where the patient facing library comes in. So from a primary care perspective, we can work with many members of the primary care team to really identify. 

what's the most appropriate way to send out these texts to patients. So we've done quite a lot of work using text batching, what we would call e coms campaigns where for diabetic patients, as an example, type two diabetic patients through the QOF register, we can identify those patients. We can send a short campaign with maybe two or three apps that they may be able to use.

And a lot of that, our team at Orca carry themselves with our clinical leads. But it's then about working with a named clinician at their end. So completely understand. It's a really busy, but actually what we find are the benefits from this. We know from some of the work that we've done around return on investment, the number of appointments that can be saved et cetera, and it's that. 

Kind of trade off, yeah. And I guess it's that starting point, which I think is true for your work, clearly, but also is true across the world is understanding the system you're working in and the workflow  and the pathway  is really So important and often is quite overlooked because everyone is so focused in exactly their busy moment of their patient interaction that understanding where that fits into a system is key when you're implementing anything is yeah, 

And absolutely you know that for me the pathway piece. Is the bit that this all hangs from, that if we're all aligned to a pathway, if we all agree that actually, yes, this is the way we're working, this is the workflow, these are the pain points we're trying to address, it makes it much easier.  

Yeah, great. Just a couple more fairly  technical questions is one around from Mahmood Alaki is asking, how do you assess the security elements when you're assessing medical apps?

And is that, and let's follow up really is there a gap there? Is there, is that a problem?  

No, it's not a problem. I think It's making sure that with all of the national assessment frameworks, and there's a slide I showed earlier with a kind of breakdown of each of the assessment frameworks across countries.

They're all using slightly different things. For us, it's always going to be ISO. It would always be the cybersecurity elements that are an NHS standard anyway for any digital product has to have passed Cyber Essentials Plus. So that's the key piece for us.  Excuse me, together with those ISO elements, but I'm more than happy to pick up a separate question, I can get into more of the detail  around that with the very clear elements from a security perspective, if that's helpful. 

Yeah, I'm sure  our participants will pick you up on that and we'll be able to contact you. I think that's the end of the questions that we've had submitted.  Think Unless anyone's got any one they want to type really quickly and we're nearly at the end of our time. So I think it leaves for me to say thank you so much, Alison for your excellent talk and overview.

It's been really interesting and and just a great overview of how you work, which gives everyone either from the UK or overseas a real insight into what's going on in the NHS in, in good practice in this way. So thank you so much, Alison. And it just leaves me to say that  you can register for our event in November, which we hope a lot of you listening will, will come and join us at, and it'll be more.

Content from people like Alison and the Orca team, but also some workshops where you can get practically into this the digital world and learn from some of the really top performing practitioners in digital health in the UK and from across the world. And the, there is the link on your screen now.

Next week let me just move my dialogue book so I can see. Yes. June the 4th at lunchtime, BMJ's specialist subject really is how to publish. And this is particularly about digital health innovations. And obviously we think that sharing is caring and sharing your innovation work is just really key to helping patients get what they need quicker and making sure that they're getting the best quality of.

Innovation in the same way that they might as we've heard today a new pharmaceutical treatment it's really important that these innovations get that sort of treatment as well. And I would like to also reiterate the call for problems is open. So that starting point of the system you're in, the problem you're facing do head to our website and look out for the link to submitting your call for problems, we'd love to hear. 

Really what problems you have. And you can go back to that webinar that Alison mentioned and watch it again, on the BMJ future health website. So thank you so much to everyone for joining us and please see you next week, hopefully. Goodbye.