The ICT health crisis: Connectivity

Around the table • Phil Brimacombe, chief information officer, healthAlliance

• Wayne Champion, general manager corporate services, West Coast District Health Board

• Alan Hesketh, deputy director general information, ITS Department, Ministry of Health

• Ron Hooton, CEO, ProCare Health

• Henare Howard, executive manager, information services, Te Roopu Taurima O Manukau Trust

• Steven Mayo-Smith, chief information officer, Radius Health Group

• Johan Vendrig, chief information officer, Auckland District Health Board

• Divina Paredes, editor, CIO

• Bennett Medary, chief executive, Simpl

• Jodi Mitchell, GM, global services, Simpl

• Rob O’Neill, editor, Computerworld

The task at hand

Phil Brimacombe: We struggle to make progress with any kind of speed, because of the number of organisations, disconnections, fragmentation and complexity of [the] health [sector]... Everyone is trying to do their own thing in their own organisation, and then trying to connect with others, that is almost too much of a burden. It’s hard enough trying to just meet your own objectives. And then when you do try and collaborate with others — for a common purpose, they don’t always agree with each other... This health system just doesn’t seem to be structured to encourage that kind of collaboration. It seems to be more structured and incentivised to encourage working locally and independently.

Bennett Medary: The issues that seem to stand before us also come up again and again and they’re about cohesion, about overcoming the traditional fragmentation that exists within the health service, both public and private. And then execution — how do you actually move from discussion around the considerations and the issues… and execute the plan against a problem set and a vision set, which we’re almost all in agreement about. The issue is the how, the how and when and how fast as opposed to the what.

Henare Howard: From our perspective, working in the NGO not for profit space, there are a lot of providers here. Unfortunately we fall outside the jurisdiction of the DHBs, and so one of the issues that we’re faced with is a lack of capacity, a lack of leadership, a lack of standards, a lack of coordination… We use a lot of the services that are provided by the DHBs and GPs. But I think one of the most challenging things is a lot of the processes and systems are still very, very manual that we’re doing. So capacity is a huge thing for our sector.

Ron Hooton: To me that’s a classic efficiency [issue]… in the sense that we’re driven towards individual parts of our system being efficient. Right, the specialists get their targets of people they have to see, the outpatient’s clinic has targets and GPs are pushing more and more people through. Each is trying to optimise their efficiency, we should be trying to optimise the effectiveness of the whole system. We’ve got a real challenge on our hands.

At a tipping point?

Bennett Medary: Do you think we’re at a tipping point? Do you think we’re anywhere near overcoming the obstacles and truly taking the sector-wide approach to managing through these challenges or do you think we’re some way off yet?

Phil Brimacombe: I don’t know if we’re at a tipping point, but certainly I feel the need to start doing something radically different. If we keep on doing what we’ve always done, we’re going to keep on getting what we’ve always got and that’s not good enough any more. We’ve got to find a new way forward and the unfortunate thing is we’ve all got to agree what that is, which is really hard and then we’ve got to go and do it. But we need to do that soon.

No shortage of ideas

Johan Vendrig: The challenge we have in New Zealand is that we have a lot of innovations, but they are in pockets and then it’s very hard for them to break out of those pockets. As information management leaders, what we could do is work with clinical leaders and try and facilitate more commonality of systems and (clinical) processes which will allow innovation to be targeted at priority areas and if successful rolled out faster to benefit a larger part of the population.

Alan Hesketh: We’re not short of very, very good ideas that actually are about delivering better health care. The challenge is… how do we facilitate the development and integration of those ideas into that common destination for the system, than actually a single organisation saying here’s what the vision is. And certainly that’s what we’re looking to try to do within the [Health] Ministry at the moment. We’re doing quite a bit of restructuring within the information directory within the ministry.

Core to that has been the creation of the information strategy and architecture group, which has that role of facilitating the development of that shared destination… We can’t achieve everything for everybody. One of the aspects we need to get is how do we establish common decision-making so that when we are beginning to move in a common way, we’re actually making decisions in parallel and in a common framework.

Ron Hooton: What I see is lots and lots of people with lots of ideas, but not a whole lot of alignment... Alignment is probably our greatest issue, not vision or innovation.

Bennett Medary: One of the challenges I see here is a difference between creation energy and deficit thinking… We can spend energy creating what it is we want and batting away the obstacles along the way, or we can recognise that clarity around the vision, that there are some things we’re going to have to get by and focus on getting them sorted first, standards and data and connectivity and so on… I see sometimes a danger that in the absence of that compelling commitment to make tomorrow sort of different, we’re left with nothing else to do except deal with the obvious deficits.

From correspondence to ‘conversations’

Johan Vendrig: Somewhere the health system got too complex for the general practitioner to be able to pick up the phone, quickly talk to the medical specialist in charge and jointly agree what the best care plan for that patient should be. So what we really should be looking for is what we can do with information technology to facilitate a clinical care planning conversation, rather than ‘tossing people over the fence’ through referral and discharge correspondence. Obviously these ‘conversations’ don’t need to be traditional voice calls but can also be online through a shared online workspace, which is the patient-centred health record.

Steven Mayo-Smith: I don’t think we’re actually making enough use of some of the more modern technologies, whether it’s Google Talk, the IMs of this world… Just as a parallel, I coach rowing. And I have whole long conversations online with somebody I’ve never met, as we sort things through. I don’t even know what the guy looks like, but he and I have these absolute conversations simply using Google Talk.

Ron Hooton: One of the things that we’re doing at the moment, is we’ve developed a derivative of YouTube, which delivers continuing medical education (CME). What that involves is usually specialist doctors preparing something between, say, a five-minute mini-update to a 45-minute or one-hour CME session that’s fully credited towards the continuing medical education requirements for the GPs... The other thing we’re doing is we’re delivering CME across WebEx, which allows GPs anywhere with a web connection to be in touch with other GPs and listen to and interact in a CME session. It’s a pretty short hop from there to be able to have a WebEx session between a secondary specialist and a ProCare GP, over a patient with a patient in the room.

Another looming crisis

Phil Brimacombe: The other big problem in health that’s driving the crisis is the workforce issues. We’d better all get used to looking after ourselves in our retirement, because there aren’t going to be as many doctors and nurses to do it for us like there used to be in the days when the GP could just ring up the specialist and have a nice conversation. It’s completely different. So that’s why I agree that patient-centred health is critical, in that we get ourselves and the public in general involved as self-provider and as self-manager of our health and of our care.

Working together

Alan Hesketh: There’s a balance of different things that are actually well outside the models of computing and health records of anything they’ve got at the moment. How does a doctor accessing an electronic record know that this person commenting is actually qualified to be able to make the kind of statements they did about the person’s health? Those are some of the things that we’ve got to crack around the sharing of information. It isn’t just the privacy issue. It’s also the ability to be able to trust it.

Johan Vendrig: To enable true collaboration (rather than consensus decision making) we need to get increasingly more trustworthy towards each other… Only then can we truly start working together, so it’s again building trust between providers to allow others to do part of your work. If we keep second guessing each other we will not go forward, instead if our decisions become more evidence based it becomes easier for others to follow.

Alan Hesketh: Let me take that trust down to a more technical level, particularly around the kind of network and intra-operability standards. We have some good standards in place around network security and the sharing of information, but they’re really based on a model — a value added network model — of how you can exchange information securely. We need to look beyond that in terms of how do we allow effective interoperability between any provider across the environment, and that’s one of the initiatives that’s actually coming out of the [health] ministry at the moment with connected health. And the sense of looking to establish what the network security and interconnectivity standards are, as well as what are the interoperability or service oriented architecture standards that actually sit on top of that… We’re looking at how we can actually structure this architecture appropriately for the health system going forwards.

Dealing with the issue of trust

Wayne Champion: We already host Rata Te Awhina Trust, the only specialist Maori health-NGO on the West Coast on the IT platform that we use for primary health. But we don’t do any sharing of information. That’s a first step in building up a relationship with them where they get to trust us as a provider of IT systems. They get a whole lot of capability that they wouldn’t have otherwise had in the IT&T arena... And we’re using that as a way of building a relationship with them so that eventually we can start tearing down some of the walls, and saying your patients would benefit if you had access to this bit of our information, and if we had access to this bit of your information.

Sharing resources

Henare Howard: Our organisation tends to be risk averse and we will share information regarding our clients with organisations we need to as and when it is required. While we would want to see clear guidelines around what information we needed to share and where that information was going to be used, I believe a cultural shift needs to take place within our organisations so that we are more open to sharing information with other agencies.

Wayne Champion: Certainly there are some things that we need to do around changing the public’s perception, and that is educating them about the benefits of sharing information, which 80 per cent or 90 per cent of them think we already do. So part of it is also educating them about the fact that we don’t. A lot of clinicians, particularly in the smaller locations [and] smaller organisations, view the relationship that they have with their patients as their relationship, and private and confidential to them. And we have to address that privacy issue and their privacy concerns, get them educated about the benefits of sharing information with other clinicians in a structured format, so that we can move forward.

Phil Brimacombe: We might want to try and have one health record shared between three key areas - the patient, primary and secondary [healthcare providers].

It takes a community…

Henare Howard: As the demographic of the population changes, we feel that there will be a growth in the amount of care provided by community-based providers and whanau members. Connected health systems will need to have the ability to connect to and collect information from a number of various endpoints to keep accurate records of an individual’s health. Ensuring that the information is accurate and verified would be a challenge.

Phil Brimacombe: One thing that needs to change for me is that regional objectives, imperatives and principles should take precedence over local priorities. Sometimes some of us will have to give up something that we’re passionate about in favour of the greater good, both regional and nationally. And that requires some significant leadership and governance.

Johan Vendrig: It comes back to basics. We have to be very careful not to design any system for any individual provider or clinician… Certainly if we want to make any consolidated investment for the next 20 years, we need to start investing in a fundamental health delivery model regardless of any organisational structure; we don’t have the capability and dollars to change our systems at that same frequency as we may want to change organisation, structures and funding models... And unless we can deliver that, we will keep reinventing the wheel and reinvesting into just doing the same thing in a slightly different way. It would be great if we could start investing in a patient-centred information system that doesn’t have to change if I choose to shift clinical activity from secondary care to primary or community care or vice versa.

Think long term

Johan Vendrig: We really feel that we are at a point that the problem’s getting too big for us to solve on our own. So I think we are owning up to the fact there’s no way that the solution lies in 21 individual DHBs or individual PHOs. But increasingly we’re saying the answer must be found a lot more in an aligned or shared solution... Therefore we’re really looking for how can we do this more collaboratively.

Alan Hesketh: The work that we’re doing is around five themes. First, we’re looking to put together a programme of work to determine what is the kind of common destination that we want to have as a Health system. Second, how do we go about making common decisions so that we’ve got a much more agreed framework for decision making across different organisations?

Third, we want to make sure that we’ve got an effective process in place to handle innovation. We’ve got to work with innovative organisations to make sure they actually fit in with the whole system. New Zealand does have a great record in innovation, particularly in niche markets.There are opportunities particularly if we want to be able to target health industries overseas, [and that] is to actually figure out how we can develop those niche applications, implement them in New Zealand and I mean [nationally], not just in one place.

The fourth aspect is around how we simplify the rollout of solutions to the populations that actually need it, and that’s through common architecture or shared services. The fifth thing we’re looking at is around the safe sharing of information. How do we make sure that people and the providers actually trust that the information they’re putting into the systems that we have, is actually going to be used in ways they expect and they understand? Those are kind of the five things we’re looking at as part of that review, trying to take away what we’re seeing as being the barriers for making progress.

The leadership imperative

Henare Howard: I think there is still an opportunity to show leadership and build momentum for this project within agencies. The Ministry could provide more information to providers and perhaps look at assistance for providers who may struggle to connect. People like ourselves should push this agenda so it starts to appear on the radar of CEOs and boards around the country. We should also look at collaborating within our own sector areas and get the momentum for this initiative moving forward. The benefits for each of our organisations may be different in each of our own areas, but the risk of not doing anything should be the motivating factor that really gets us moving.

Alan Hesketh: That is actually the crux of it… trying to re-establish the right type of clinical leadership so we can actually take these things forward [on a] national basis. It’s starting to happen and there’s the Cancer Network that’s operating at the moment. We’ve got Guidelines New Zealand, which looks at clinical guidelines for how we treat different diseases or conditions. And it becomes a case of how can we actually get the right kind of clinical leadership in place, to be able to take away that difference in approach as being a barrier to delivering the same quality of care wherever you are… One of the government initiatives around now, is actually looking at the clinical leadership and part of the ministerial review group that’s going on at the moment is tasked with doing precisely that. It’s looking at how can we strengthen clinical networks and make viable clinical leadership more effective going forwards.

NZ as a ‘teaching nation’

Bennett Medary: The ‘teaching nation’ concept is about having some aspiration for the health system that we can all align to. What if we apply that kind of ambition in the New Zealand health service and create a climate of innovation and collaboration and research which begins to attract the best health professionals, the best health administrators in the world, and fosters a New Zealand supply industry and encourages them to bring innovation? New Zealand [then] becomes seen in a global context as a teaching hospital, as an extremely attractive place to become a health professional… The teaching hospital metaphor whether we take it seriously [means] there is a huge ambition to be the best and advanced [in] science-outcome medicine… It becomes a virtuous cycle.

Simpl kindly sponsored the CIO Roundtable on 'The Health Connection Crisis'.