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Reaching the e-health promised land

There is broad consensus about the need for significant e-health improvement in the Irish health system as we begin 2020. However, with slow progress in the area, David Lynch surveys the current situation

During a debate on the need for a national electronic patient record at last year’s IMO AGM, NCHD committee Chair Dr Paddy Hillery described his own experience in emergency medicine.

“Every time a patient comes in to me, the first thing they say is ‘sure, you have it all on my record, doctor’ or ‘you have it all there, you know my medications and you know my allergies’, or they say ‘I’m allergic to that thing; I can’t remember what it is, but sure, it is in my record’.”

Dr Hillery said patients, who have grown accustomed to having much of their personal and professional lives digitalised with easy online access, would be shocked at the lack of electronic record capacity and co-ordination in Irish hospitals and the wider health system.

Important progress is being made in different sites across the country. For instance, last year Cork University Maternity Hospital was the first site to launch the Maternal and  Newborn Clinical Management system (MN-CMS), which is due to be the first step in a national project that will introduce an electronic health record across all 19 maternity hospitals in Ireland. Since Cork’s adoption, further sites, including the Rotunda Hospital, the National Maternity Hospital and University Hospital Kerry have also gone live with the system.

In October, the HSE unveiled a new information system at St Luke’s Hospital, Rathgar (Dublin), that is linked to the National Cancer Information System (NCIS). The NCIS project is led by the National Cancer Control Programme in conjunction with the HSE Office of the Chief Information Officer (OoCIO) and the HSE Acute Operations Division. It was established in response to requirements identified by medical oncology consultants and other health professionals.

There are other e-health projects that have begun in recent years and more that are due to start (see www.ehealthireland.ie for further examples).

However, at a national level e-health and EHR implementation appears somewhat stalled. The HSE has previously finalised a EHR business case, which was approved by the HSE Leadership team in the spring of 2016. The case was submitted to the Department of Health but since then, progress has halted. The Executive is currently revising the case following requests from the Department.

“The Department have not approved the business [case] in its current form because of concerns raised regarding the scope, cost and proposed procurement approach,” a Department spokesperson told the Medical Independent (MI).

“The HSE have been tasked with revising the business case to address these issues and we have jointly agreed a way forward for sites affected by delays associated with revising the business case.”

By the time of going to press, the HSE did not provide a date for when this revision is expected to be finalised.

On the medical side, there is some empathy with the scale of the task facing the HSE.

“I have a slight bit of sympathy for the IT guys in the HSE,” Meath-based GP Dr Maitiú Ó Faolain told MI.

Dr Maitiú Ó Faolain

“They are committed. But they are also at the mercy of DPER [Department of Public Expenditure and Reform]; the process for getting IT projects on board is slow. Sometimes, political priorities override what might be a clinical priority. E-prescribing has been talked about for probably six or seven years, and it’s just getting around to being delivered.”

Dr Ó Faolain said e-prescribing must be the focus for the HSE in 2020.

“It’s slow to get started, [but] I think most GPs are light years ahead of the rest of the health system in being IT-enabled,” said Dr Ó Faolain.

“I know the IHI [individual health identifier] needs to come about, because that is the building block for e-prescribing.”

Scale

Dr Ó Faolain added that he believed GPs have proved they are enthusiastic adopters of new technology, but “there have been e-initiatives that GPs have not come on board with, because it would not work in general practice. We are not abandoning our really expensive computer system for an inferior product, just because it was someone else’s pet project.

“But if people involve general practice in the beginning of their new IT project, they will find GPs co-operative.”

Speaking to MI before Christmas, the HSE Director of Digital Transformation and Open Innovation, Mr Martin Curley, said the scale of the work he is currently involved in is one of the biggest challenges of his career. Mr Curley was formerly Vice-President at Intel Corporation and Director of Intel Labs Europe.

“A company the size of Intel would have 100,000 employees all over the world. The HSE would be of a similar scale, in fact a little bit bigger, and has even more complexity than somewhere like Intel has,” said Mr Curley. He  was speaking to this newspaper following a presentation in late November at the Health Informatics Society of Ireland annual conference at Croke Park, Dublin.

“Building a Fab [Intel plant] is hugely expensive, but to maintain a health system is as expensive and is much more complex. But today, there are sophisticated tools which [private] industry has deployed [at a] much more advanced [level] than we have in healthcare… because we haven’t really invested appropriately in technology.

Mr Martin Curley

“So the goal is to transform the HSE from the outside in, working with partners, so we can all invest together so we can actually get the scale we really need to drive real and meaningful change.”

As reported in this newspaper in early December, Mr Curley told MI that “vital signs automation” for Irish hospital wards should be introduced before an electronic health record (EHR). “I think the problem is that EHR hasn’t been delivered and it’s late.

“So personally, what I would say, what we need to do first before we do EHR is vital signs automation. Currently, there is €800 million slated for EHR; we could take a fraction of that and automate our wards first so they would be way safer — that is the first thing I would do. Basically [it means] automating vital signs collection such as automated blood pressure monitoring, pulse rate, etc.”

Mr Curley said this automation of wards could be done “shy” of the introduction of EHR.

“It could be done first — in fact, it should be done first,” said Mr Curley.

‘Good collaboration’

Mr Curley was the Chief Information Officer (CIO) at the HSE until the end of 2018, before he moved into his current role, which did not exist before. He told this newspaper that he had “good collaboration” with the acting HSE CIO Mr Fran Thompson.

“The CIO is responsible for running all the operational service and enterprise architecture and what I am responsible for is digital transformation … very often, that change is going to come from the outside in, so it’s probably not fair to rely on the CIO and the IT staff to be the drivers of change,” Mr Curley told MI.

“The role of [the] CIO is very complex, particularly in the HSE, [the office] is understaffed; it is a very difficult job.”

Mr Curley said that in his current position, he had “developed this approach called ‘Open Innovation 2.0’… which is where we get alignment from Government, industry, academia, citizens and patients and we have a common vision to transform the Irish health service over a five-to 10-year period.”

When asked about the changes in the leadership of e-health in the HSE, an Executive spokesperson told MI that “the Office of the Chief Information Officer (OoCIO) is the HSE office responsible for the delivery of information technology to support and improve healthcare in Ireland.

“The OoCIO is committed to realising the e-health Ireland strategy by ensuring that information and technology support healthcare efficiently and effectively throughout the whole health service.”

The HSE confirmed that Mr Thompson’s title is still Interim CIO. “It is a full-time position on a temporary basis; [he] has been in this position for 12 months,” according to the spokesperson. Mr Thompson was not available for interview before MI went to press.

When asked how the OoCIO and Mr Curley’s office work together, the HSE said “they are broadly complementary, but in very different areas”.

According to figures supplied to this newspaper, as of November 2019, there are 320 staff (WTE) working in the OoCIO and its budget for last year was €49.2 million. This year, the budget has increased to €51.3 million.

Asked about staffing in Mr Curley’s office, the spokesperson said: “[Mr] Curley is leading out on digital transformation agenda items including the initiation of a Digital Masters Programme and is currently supported by two staff members.”

The spokesperson added that “although there would be close working relationships, the OoCIO are separate [and] there is no staff-sharing”.

“Martin Curley’s department budget is covered under the overall HR [human resources] budget. There is no separate budget for the office.”

Engaged

Mr Richard Corbridge was the first HSE CIO and left the position after three years in 2017 to pursue new roles in the UK. He talks fondly of his time at the HSE and the work he did there (see below).

“My time in Ireland is the best time in my career to date; we achieved a lot by working differently,” Mr Corbridge told MI.

“Largely, the team were engaged, wanted what we had to offer and understood the need. I had the best boss a CIO could ever ask for in the DG [Mr Tony O’Brien] at the time, knowledgeable and yet willing to hear your voice, aware and yet willing to throw in an opinion and a true leader of people. These ‘forces’ are needed to create success.”

Mr Corbridge added that there was political support at the time. “During my time as CIO, the political elements of the health sector also understood the need for a digital change. Gaining and keeping that level of support was so important to the success we had during those years,” he said.

“Ireland and the HSE has talent like nowhere else I have been able to deliver. That talent needs to be empowered, allowed to deliver.

“The road blocks that the system has become cultured to putting in place is where the role got difficult sometimes. However, these road blocks were predominantly well-intentioned checks and measures, just not always necessary.

“Take the delivery of the digital maternity strategy, a document created through rapid engagement with every maternity hospital in Ireland in 24 hours. Proof that when you do something the system isn’t expecting that works and is good, a different way of working can be achieved. 

“The healthcare system needs digital solutions to reform and provide the best healthcare system the citizens of Ireland could ask for. One of the best parts of the role in Ireland was being able to impact on this, although in only small ways.”

Mr Richard Corbridge

However, looking back at some of the structural changes made since he departed, such as a split in priorities between the OoCIO and office of the Director of Digital Transformation and Open Innovation, Mr Corbridge is somewhat sceptical of its benefits.

He said such a set-up is “far away from best practice for so many reasons and is the sort of structure that healthcare systems and indeed commercial organisations across the world are failing because of”.

“Who can make transformation happen and most importantly, stick? The CIO, the person working at the frontline seeing the need and bringing the right partners to the fore to help solve the problems,” he said.

“I do think the CIO should have a lead within their team for innovation. However, it has to be part of the function of delivery to be successful. I would go as far as to say the role ought to be clinical more than it ought to be digital.

“Ideally, the CIO would have two arms to their capability: One that delivers excellence day-to-day and is responsible for the supply of digital. The second arm is responsible for considering the future, the demand for digital and is as much a clinical engagement and transformation capability as it is a digital function.

“To separate these two roles goes against best guidance from learnings from across the world and without very good governance is at risk of delivering cool technology that nobody needs, or worse, still spending money without knowing what benefits will be delivered.”

Mr Corbridge added that this structure “is almost guaranteed to create ‘silo thinking’ and indeed create the environment for a ‘turf war’ to emerge. This is something the digital leadership needs to resolve, not to add to with its own structures and therefore, I would urge a review of this that sees a single leader of digital in-post for the whole healthcare system.”

IHI

For its part, the IMO said it is hopeful that this year could see progress in e-health.

“The recent GP agreement sets out a number of transformative e-health initiatives to be achieved over the lifetime of the agreement,” Mr Val Moran, IMO Director of Industrial Relations, General Practice, Public and Community Health, told MI.

“One of the key measures set out in this is the individual health identifier (IHI). The legislation underpinning the IHI Health Identifiers Act 2014 was passed by the Oireachtas in 2014 and commenced in 2017. It is vital now that that work is done on making the IHI a reality.

“An IHI is a number that identifies each person who has used, or may use, a health or social care service in Ireland.  Each individual will be assigned their own personal number, which is unique to them. 

“The main benefit of having an IHI is to uniquely identify each service user and therefore, improve patient safety by reducing errors that might happen, such as ensuring patients receive the correct medication, vaccinations, and treatment. It is also a building block that will allow a lot more development in the e-health space.”

Mr Moran noted there is “always an element of building the plane while flying it with the Irish health service”. He added that this situation “makes it somewhat difficult for longer/medium-term issues to have the focus that they perhaps should. E-health is an important part of the health agenda and should be integral to all parts of health service planning.”

Challenges for e-health — the past, present and future: Reflections of a former CIO

Mr Richard Corbridge became the first HSE CIO in 2014 and remained in that post for a busy three years. Since then, he has worked in the UK and has been Chief Digital and Information Officer at Leeds Teaching Hospital Trust (LTHT) and last year, he took up a position as Director of Innovation at Boots.

What does he see as the major challenges facing Governmental health bodies like the HSE when it comes to the implementation of e-health?

“Understanding the benefit that digital can bring to healthcare systems is a challenge that is being repeated across the world today,” Mr Corbridge told MI.

“As more systems understand the way digital can offer a platform for safety, for efficiency and for convenience, healthcare systems have started to invest more appropriately in healthcare technology.

“When we have businesses from other sectors moving to become ‘digital first’ businesses, it is hard to comprehend how healthcare systems can possibly think this should not be the same for the delivery of healthcare in 2020.

“A huge amount of engagement work has been achieved across the Irish health system. The advent of the Chief Clinical Information Officer roles led the way for the rest of the world to follow and was applauded by the WHO [World Health Organisation]; a continued focus on this is entirely necessary.

“Digital solutions have to be deployed to the ‘customer’ in healthcare; that is, the clinician and the patient and not to the IT teams that support individual organisations throughout the system.”

Mr Corbridge said he believed that “more thought” needs to be “applied to the engagement of every part of the system in the digital journey if it is to be successful. Ireland, like other jurisdictions, needs a figurehead for digital healthcare delivery.

NHS X (www.nhsx.nhs.uk) has made a huge difference to the perceptions of what technology can do for healthcare in the UK; eHealth Ireland can be the same difference-making vehicle if given the opportunity.”

Mr Corbridge said investment is important, and the business case that the HSE made for EHR will have to be significantly reassessed.

“In the UK, the Secretary of State for healthcare has placed digital as a priority and a foundation for investment. In his first policy speech after the election, he has indicated a need to invest in the whole healthcare systems digital capability and he has followed this up with how this investment can be made, monitored and governed,” said Mr Corbridge. “Digital change needs to be done quickly; governance in healthcare systems is too slow to cope in the way it is currently created. The EHR business case for Ireland was developed when I was CIO, it has not been delivered and therefore is now out of date. It will need new costs and new benefits to be defined, because technology has changed and will continue to change.

“My ask would be, write a business case, approve the business case, create the delivery partnerships and do this in nine months. Then set targets with matching resources that see systems making a difference as a minimal viable product in six months or less.”

Does he think doctors and the HSE have grasped the importance of e-health?

“It had, as had more importantly, the citizens of Ireland. Patients want efficient, convenient and safe healthcare that is joined-up, a system that is transparent and has a learning culture. This simply cannot be delivered in 2020 without digital,” said Mr Corbridge.

Quick steps

“Healthcare systems need to be able to see change happening in small but quick incremental steps, numbers of people able to access technology need to grow and systems need to be easy to use. Ireland has a wealth of partners available to it in its ecosystem.

“This ecosystem needs to include the engaged clinicians and the leadership of the HSE and Department [of Health]. Remember, Ireland was one of the first countries in the EU to agree a ‘cloud-first’ policy, to create an innovation week, to deliver health identifiers infrastructure, to use the sequenced genome in the delivery of care and to agree ways forward with clinicians for referrals, e-prescribing and other initiatives.”

But there is a perception, at least among some in healthcare in Ireland, that the e-health agenda has slowed somewhat. Why does Mr Corbridge think this is?

“I suggest, because engagement has slowed, because operational pressures have become stronger and stronger and therefore the priority of making this ‘stuff’ happen has slipped,” he told MI

“The importance for digital in health can only be continually grasped if the foundations of a digital healthcare system are delivering a backbone that can be built upon.

 “The authorities could and indeed now need to demonstrate that they do grasp the importance of digital to a healthcare system of excellence. The concept of eHealth Ireland, a credible delivery function with some degree of authority, to ‘just do’ needs to be dusted down. The Department’s suggestion was described by other jurisdictions as ‘best in class’, therefore adopting this already agreed principle and function and placing the CIO of the HSE as the CEO of eHealth Ireland and empowering it to deliver with the right resource will be instrumental in delivering the healthcare system that clinicians want to work in and that the citizens of Ireland deserve.”

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