The road from original idea to eventual implementation in healthcare practice is long and complicated. Many well-conceived healthcare innovations do not make it to the finish line. The SenseGlove project of a consortium consisting of SenseGlove, CleVR and Rijndam did make it. Baking eggs and pouring coffee with VR goggles and a haptic glove: Rijndam has begun implementing it in hand rehabilitation and is evaluating how patients and therapists work with it. The innovation project was supported by the ZorgTech innovation program.
What learning points do the consortium members take away for subsequent projects? What would they have preferred to do differently in hindsight? And what tips do they have for other healthcare innovators? We spoke with Medical Delta postdoc Bram Onneweer of Rijndam Rehabilitation and Guntur Sandino, founder and owner of CleVR, about the innovation process and implementation process that followed. "There is always more possible from a technological point of view, but at some point you have to dare stop and concentrate on implementation."
Hand rehabilitation for people who have had a stroke is perceived as intensive. Rehabilitators sometimes have to perform the same exercises hundreds of times. Thereby, exercises for daily actions, such as cooking or pouring tea, can be dangerous. Moreover, they are labor-intensive for the therapists who have to manage everything.
Over four years ago, SenseGlove, CleVR and Rijndam started a pilot project to implement hand rehabilitation in a different way with the SenseGlove glove (that recently won the KvK Innovatie Top 100). The company CleVR developed a virtual reality environment in which rehabilitants are challenged to use the glove to perform actions in a virtual kitchen, such as frying an egg or pouring tea. The glove makes it possible, through force feedback, to actually feel the actions performed in the virtual world.
Therapists and patients showed enthusiasm and the consortium successfully applied for a ZorgTech voucher. Meanwhile, the innovation process has been completed and Rijndam has actually started to implement it in rehabilitation treatments. This is the final phase of the project and in it they are evaluating how patients and therapists are working with it. Bram Onneweer and Guntur Sandino enthusiastically share their experiences. We summarize them in five learning points.
"Involve the end user and partners in the innovation process on an ongoing basis. And do so even when it doesn't seem relevant," says Bram Onneweer of Rijndam. "For the further development of the exercises, we gathered useful input from hand therapists and their patients. However, in the months when we processed their feedback into an improved version, we did not include them sufficiently in the process, so the attention and knowledge gained slowly disappeared, which is of course a shame." Guntur Sandino of CleVR underscores this importance. "For us as a software developer, the therapists' input was very valuable. Rijndam made sure that the threshold was low and we were able to work with them quickly to determine the needs and minimum requirements."
Innovation is also important for healthcare organizations, otherwise you get stuck in a vicious circle of no time and no money for innovation and improvement
The allocation of a voucher from the ZorgTech innovation program helped, Sandino says. "It allowed the therapists to free up more time to think with us. What also helped is that Rijndam sees the value of innovation. Innovation is also important for healthcare organizations, otherwise you get stuck in a vicious circle of no time and no money for innovation and improvement."
Gradually, the therapists gained more ownership, from which the project benefited. As an example, both cite an adaptation of the objective. The SenseGlove can collect data, such as how exercises are performed. Very useful information for the therapists, Onneweer and Sandino thought. But the therapists themselves saw this differently. They actually experienced data collection, analysis and interpretation as an extra burden. They saw much more value in optimizing the glove as a practical exercise tool. "From then on, we put our time and development effort into data collection and focused entirely on the exercises," Onneweer says.
An additional benefit of co-creation with end users, is that it facilitates final implementation: "Because our therapists themselves participated in the development, we can now quickly put it into practice," says Onneweer.
There is a big difference in what is technically possible and what turns out to be workable for the end user, Sandino says. "Even for this, the input of the therapists was leading. We can think of all kinds of things technically, but if they can't handle it easily, it will cost a healthcare organization extra time for courses or treatment. Our starting point was therefore that the therapists must be able to use it without much explanation or start-up time. We tested usability with them several times."
Clear goals for the innovation project helped. But also afterwards. Onneweer: "Before you know it, you are so focused on the innovation itself that you lose sight of what the impact of the innovation is on the overall care process. What does an innovation mean for existing treatment pathways? For therapists, for patients? Think about that in advance." For Sandino, creating and monitoring a business plan has also been important in this. "Map out the costs and benefits of the innovation and take that as a starting point for further development."
What you must realize each time you do this is that the technological innovation must replace something and not add something, Onneweer argues. "If an innovation or technology comes on top of an existing treatment, it means more work and more costs without direct compensation. The result: the innovation eventually ends up in a drawer. Therefore, make sure the innovation replaces an existing treatment and realize what the impact is for the end user."
Make sure the innovation replaces an existing treatment
"What actually applies to almost all innovations in rehabilitation care is: stay within the same time and cost of an existing treatment," says Sandino. "If it says 12 hours for a given treatment, that's your maximum. Rather, achieve the same goals with less time. Another pillar of your business case is that the innovation makes the treatment at least as good, but preferably more effective. So suppose the treatment duration remains the same, but thanks to the innovation, a therapist can have multiple rehabbers practicing simultaneously. Then, too, you have a good starting point for your business case. Include these kinds of preconditions from the beginning of the innovation process."
Once the goals are set, it is important to act on them. Specifically, this means making choices between possibilities and necessities. Onneweer: "In multi-year projects like this one, the technological possibilities continue. If you're not careful, those possibilities take over. You have to have the courage at some point to put a stop to that: now the technology is good enough for the goals we have set, we are now going to spend our time implementing it."
As a software developer, this is a familiar fact for Sandino. "End users can overshoot in their enthusiasm and come up with many additional wishes and suggestions. Very welcome of course, but you have to dare to set limits at some point. We also did this together with the therapists: together we determined what was really necessary and what was more 'nice to have'. Kill your darlings. Also realize that, especially for a pilot, it doesn't have to be 100% perfect. Therefore, consider a pilot as such and not as a final end product: good enough is good enough if it achieves the goal you have in mind."
It is important to know your role in this, Onneweer says, and to make choices in this as well. "As a rehabilitation center, you shouldn't want to come up with a whole new technology. We concentrate our innovative power mainly on applying innovations that are already there. The SenseGlove already existed for some time; we worked with them and with CleVR to see how we could apply it optimally for hand therapy."
Although the SenseGlove is now being implemented and evaluated in rehabilitation programs and therapists and patients are enthusiastic, its use remains limited to Rijndam alone for now. This is due in part to funding. Onneweer: "The wry thing is: if a technological innovation reduces treatment time, it also reduces income for therapists and rehabilitation centers. Working more efficiently is not directly reimbursed; a perverse incentive in the system precisely not to innovate."
On the other hand, according to Onneweer, there is the will of therapists to ultimately provide the best possible treatment to their patients. And for health care institutions, for example, it also means that you have to look at what an innovation brings indirectly, such as satisfied staff and patients, or greater volumes by taking in more patients. "Those are things you can include in the business plan of your innovation project."
A prerequisite for insurers is that an innovation be proven efficient, but that's still quite difficult in this case, says Onneweer. "You can't compare rehabilitation patients one-to-one with each other. And to calculate averages, we need at least another year to collect sufficient data. Finally, it is also difficult to determine what the final effect is: every patient sets different goals, therefore it is a subjective assessment to what extent a rehabilitation is successful or not."
From the beginning, think not only about funding for the development process, but also about sufficient budget for implementation and market entry
And yet it is necessary to get the effect proven. "For scaling up, insurers ultimately have to see the added value," says Onneweer. Good thinking about the business case therefore remains important before, during and after the innovation process. "Thinking across projects also means continuously evaluating whether an innovation has sufficient added value for a group of patients, and whether that group is large enough. From the beginning, think not only about funding for the development process, but also about sufficient budget for implementation and market entry, for scaling up and for funding from insurers."
It is one of the things he would have done differently with the knowledge of today four years ago, at the start of the project. "Thinking more about: what will it cost? And better understanding for how many patients this can be a solution for and how it helps therapists and rehabilitation centers move forward." Sandino adds: "The project is successful for Rijndam, but on what scale do we move forward? Rijndam also has to think about this and make trade-offs. We do not yet have a definitive business case. The unfortunate thing is that subsidies can often be found for the development of an innovation, but less so for its implementation. Collecting evidence in an RCT (randomized control trial) to qualify for reimbursement from insurers is a barrier. Often an RCT takes several years, and by then the innovation will have been superseded by newer, better technology. For now, we mainly want to capitalize on the user experiences and hope that other rehabilitation centers will pick up on that."
The mutual cooperation also continues in other innovation projects. "We have had excellent experiences together, the low threshold at Rijndam to end users has really proved to be of added value for us," concludes Sandino. "There is no management layer in between, which you sometimes see at other organizations, so we got direct input from the end users. We now collaborate on other projects as well. With SenseGlove, we had an excellent collaboration technically. It helped that we already knew SenseGlove and Rijndam. Good communication between them allowed us to work efficiently." But beyond that, and perhaps just as important: "It was also super fun to do this together."
The ZorgTech innovation program is made possible by the Rotterdam The Hague Metropolitan Region (MRDH), the province of South Holland, TNO, InnovationQuarter and Medical Delta; implementation is in the hands of InnovationQuarter, Medical Delta and TNO.