DITO was proposed to Innovate UK in October 2018 under the Digital health technology catalyst round 3 competition, as collaborative industrial research. The application's statement of intent still reads as the project's clearest self-definition, and this page draws on it directly.
The need
The application began from the deteriorating patient. Many patients still experience sub-optimal care leading to adverse clinical outcomes - unplanned intensive-care admission, emergency surgery, cardiac arrest and death; an estimated 7% of in-hospital deaths are preventable (NCEPOD, Emergency Admissions). The healthcare need aligned with the NHS Improvement patient safety alert of 2016: reduce avoidable mortality and morbidity of deteriorating patients, improve the identification and management of sepsis, and implement NEWS2.
Behind the clinical need sat a structural one. Observation practice was still largely paper-based, and the incumbent digital systems were closed: lacking interoperability, closed to clinical scrutiny, costly to acquire and iterate, and a barrier to the evolution that clinical progress requires. The NHS needed digital technology it could govern - where clinicians manage the roadmap, a competitive supplier market exists without lock-in, and governance covers safety, ownership and sustainability.
The vision
The application put the vision as three transformations:
- Transform the clinical process to be optimised for digital delivery.
- Transform the translation of clinical process to logical process.
- Transform the method for delivering digital health technology.
In other words: not just a better application, but a better way of producing clinical applications - packaging up the whole approach from clinical definition through to digital delivery, so it could be repeated across the NHS.
Objective 1: Best-practice open digital health
A key objective of this project is to develop, prove and document processes and best practices which enable sustainable, joined-up and safe systems suitable to support a modern digital healthcare system. An open approach will be taken to all aspects of this projects and assets developed in the open.
These values are described as:
Sustainable: the ability to explore, understand, improve and further develop digital systems used by the public healthcare sector
Joined-up: the ability for independent systems to co-exist and inter-operate whenever necessary in a reliable and predictable manner
Safe: the ability to study internal workings, validate safety claims, remedy issues discovered
Using an Open approach : all aspects of the approach, from supplier engagement and definition of need through software development to safety assessment and implementation will be approached openly
Developed in the open (DITO): assets including software and documentation will be created in line with the documented Apperta DITO standard
The application committed the project to evidencing this objective, not just asserting it: evidencing the approach through structured academic, clinical and technical research; sharing the evidence-based results with the public health sector throughout the process; and evidencing new governance processes for managing digital technology for the public sector.
The process is designed for the NHS although will be broadly applicable to any public administration UK and global.
Objective 2: Digital application to evidence the process
To prove the processes developed, a digital clinical application will be developed alongside the overall objective. A nursing observation application (eObs) has been selected as the test case for this project as the technical and clinical partners are already familiar with the problem space and have worked together on existing prototype.
A fit-for-purpose eObs application provides an essential support system to reduce deterioration of patients and inform the rapid response processes.
As the application framed it, the goal was a proof-of-concept open standards-based digital application that meets the clinical need, delivered within the governance structure, which can be integrated with other applications and can evolve in perpetuity. Distinctively, it combined NEWS2 monitoring with clinical noting of the response - maximising clinical content and reducing cognitive error, rather than recording numbers alone.
How the project set out to do it
The application described a research arc drawn from translational medicine, moving from evidence to practice in five steps:
- Research current practice - paper-based and the embryonic use of digitally recorded observations in the NHS - leading to evidence-based design decisions.
- Analyse the research and generate a hypothesis for the optimum approach.
- Test through high-fidelity simulation, enabling thorough and consistent measurement in a simulated hospital ward.
- Implement the digital solution that delivers the approach.
- Validate the approach in a live setting through pilot activities across the two NHS trust partners.
What made it innovative was the working arrangement as much as the technology: clinicians, technologists and academics working closely to define new best practice; a system designed, created and used by clinicians, owned and governed under NHS custodianship, and developed by an SME - with open source, open standards and open platforms removing integration barriers and vendor lock-in, and enabling future evolution.
How each partner carried these roles is on the team page; what the project delivered against them is recorded in the outputs.