The blog article below was originally published in the European Journal of eHealth law and Policy, it is a longer blog article than normal for here but may be a good reflection of the current situation in Ireland and what we are trying to do and how we are going about it…
The concept of technology providing a bedrock for countries that have a need to reform their health systems is well understood. Globally healthcare has been slow to adopt technology at a country-wide level and to make a difference to the delivery of healthcare system through digital solutions. Ireland is trying to be different and achieve a system reform supported by eHealth from the very beginning.
Ireland has underinvested in the use of technology to support the delivery of healthcare; this is a matter of public record. The average investment across Europe is between 2% to 3% of the health budget; in Ireland in 2013 it was 0.85%. However at the end of 2013 a decision was taken to consider how information technology could create efficiencies in the delivery of a healthcare system facing equal challenges to any other global system. One with an aging population, a population explosion of long term conditions and a national concern in the ability of the healthcare system to support the country, all globally recognisable factors in the need for reform of the health provision.
The healthcare system of Ireland is complex, neither free at the point of care like the NHS nor a truly pay as you go system like the USA. This adds a unique challenge to the delivery of eHealth to a nation. But, as the saying goes, with challenge comes opportunity.
The position of eHealth within legislation is a relatively white piece of paper for Ireland. In the summer of 2014 the health identifiers bill was passed, allowing the creation of a health index for the purpose of identifying patients traversing the healthcare delivery system. Unlike other countries where this has been done, Ireland is able to learn lessons from success and failure elsewhere and create the legislative catalyst required to kick start the eHealth movement.
In 2010, the Irish Health Information and Quality Authority listed the health identifier as being ‘the single most important deficiency in the health information infrastructure of Ireland’. By the middle of 2015 the first phases of the Individual Health Identifier (IHI) will be live. One of the lessons that eHealth Ireland has learnt from other countries on this journey is that of engagement and how to get it right.
An industry engagement process is underway throughout the healthcare IT providers’ industry to understand how they think eHealth could be delivered to a country of around five million people within Europe. There have been some fascinating elements learnt from this engagement, including that any development should be procured on an outcomes basis and that we must begin the journey with as open standards as possible. One of the crucial items though is to begin to create the strategy for the overall delivery model for Ireland.
The healthcare IT industry had been approaching senior officials of the healthcare system in Ireland for many years to say that if this problem was handed to them they would know what to do. What has become clear during the industry engagement was that they don’t really and that they need the healthcare system informatics professionals, clinicians and patients to show them the way. This therefore leads eHealth Ireland to create a much more comprehensive engagement process than has ever gone before to ensure that the patient is at the centre of the benefits being sought and that the clinician is part of the design process.
Four key items to get right from the beginning of eHealth implementation for Ireland are learnt from the speed and perhaps haste that some other countries have implemented:
Consent model – Ensuring public engagement in the consent model is essential but also creating the technology element for an all-encompassing consent model is also critical. Flagging consent, or not, in the many healthcare IT systems in the UK has resulted in a multiplicity of options that are confusing to the patient. In Ireland an attempt is being made to capture consent for the sharing of information for the provision of healthcare just once, with a further consent capability created but not yet populated for information to also be used for research. Consent for research can then be considered at a time when the public, the system and the government are ready to do so, thereby avoiding the lengthy debate that has slowed down other countries.
Clinical engagement – The UK’s eHealth Insider campaign to create a council of Chief Clinical Information Officers (CCIO) is an area that eHealth Ireland will also learn from. The creation of the CCIO role throughout the Irish health system is a desire of eHealth Ireland. eHealth Ireland will firstly use the already populated and enthusiastic eco-system in place throughout Ireland to drive this forward before moving to roles within the healthcare system with responsibility akin to that of the CCIO. The desire from clinicians to be involved in the process of defining the eHealth systems that they will use in a digital health service at such an early stage indicates that the engagement of clinicians in Ireland will perhaps be easier than in countries that have set on this path previously.
Integrated care – A clear objective of a digital support infrastructure for health is to integrate its provision. Ireland, like many European countries, is facing a crisis within the provision of emergency care and digital links to primary and community care will ease this crisis. An early target outcome for the programme will be to provide systems that both enable a better integration of care for the patient and enable them to be cared for in the best possible setting or indeed allows citizens access to information that keeps them out of the care settings. Keep the well better and not in the health system!
Interoperability and standards – From the beginning eHealth Ireland is not going to attempt to put in place one system that fits all solutions, despite its relatively small size. To move a population to one technology solution that delivers for all therapeutic areas is likely to hamper engagement; the Irish healthcare system has around 1,700 different systems currently deployed after all. With this in mind the delivery of a standards-based approach to interoperability is an opportunity that has to be delivered. The desire to have as open standards as possible across all procurements of new solutions has been expressed in the new strategy development.
The operating model for the delivery of digital solutions into a geography that is best described as a ‘brownish green field’ has to be different to what has gone before. The role of the technology in healthcare in Ireland has been very much a localised delivery of excellence and innovation, perhaps set against a national system that could be seen to have stifled this through attempts to standardise solutions and enable an interoperable environment with very little funding. The new operating model and strategy for the delivery of knowledge and information will be released by the end of March 2015. Even the title of the strategy has been agreed to mark a change in attitude to what has gone before.
Knowledge and information are the outcomes that a healthcare delivery system wants from a digital solution, hence the new strategy and even operating model, placing these concepts at the very heart of what is being proposed for Ireland. The operating model for digital delivery in 2015 is aligned to the healthcare structures, with clinical and patient outcomes being the key performance indicator of each of the delivery programmes.
The first deliverables within this new operating model are the creation of a technical design authority and the support of the Irish Health Information and Quality Authorities public consultation on the information governance standards for the IHI. The system’s desire to consult with the public of Ireland and ensure that the standards and capability for supporting the very first piece of national infrastructure sets a useful precedent. The consultation has been created to provide the public with an opportunity to express opinions on how the IHI will be used and to ensure that they are satisfied with the way in which this information is accessed and managed. The IHI, after all, is the first time there has been a national identifier for the healthcare system, which is quite a leap of change for patients and public.
The concept of an Information Governance tool kit similar to that which has evolved in the NHS is also an area that Ireland will learn from and adopt. First facilitating improvement in information governance standards across health organisations throughout the country and then putting in place the ability for organisations to audit and regulate themselves is crucial. The legal framework for the use of the IHI is in place, the framework that will govern the sharing of information across organisational boundaries is being developed. Other countries have in the recent past struggled to link the legislation to the actual delivery; this is something that Ireland is in a position to avoid. The Health Information bill is being developed in conjunction with key stakeholders. Full consideration is being given to what the clinician needs a digital infrastructure to achieve to support the creation of integrated care pathways, in addition to what is expected by the patient from a privacy point of view. The creation of the Health Information bill will provide the required impetus and governance for the delivery of patient outcomes through digital health.
A design authority is now in place in Ireland to provide support to all solutions that are considered part of the eHealth eco-system both currently and in the future. The delivery of digital health provision to a system so in need of it could not wait for procurements of new systems, and nor should it. There are pockets of excellence throughout Ireland that through adoption of design principles, governance standards and a framework of interoperability, can begin the cultural shift required in health to adopt digital solutions. A goal for Ireland is to halve the benefit release time seen in the NHS for solutions such as the Summary Care Record, now, proudly delivering a summary record to 9 in every 10 patients, but a whole 10 years after the first record was created.
These pockets of excellence show the Irish capability to innovate in a different way. Many have suggested that digital health innovation is almost an expression of Irish culture, doing it despite the environment created to facilitate it. The concept of vertical innovation, not merely repeating what has gone before has been applied in localities, never more so than in the two examples described below.
The delivery of eReferral in the cities of Cork and Kerry one would suggest is not doing something different, until you understand how it has been delivered. A full primary care referral digitised with very little funding or resource, primarily through the sheer willpower of an excellent project team and the desire to deliver an agile referral process on the part of the hospitals in those areas. This pilot can now be industrialised and implemented throughout Ireland at a pace appropriate to the change capability of hospitals, rather than technology delivery.
The other area of excellence demonstrated is a unique Electronic Patient Record system, a solution that makes digital the provision of Epilepsy care throughout the nation. Clinically lead, built from within the system and opened up for a system supplier to then support, the solution provides a mobile digital solution with inherent information governance for the delivery of integrated care throughout the pathway. The next stages for this project will be to connect it to solutions like the IHI and to ensure that the data locked into the system can be made available to patients to enable self-management of their illness and also so that clinical staff can make secondary use of the information.
So the future is bright for delivery of eHealth on the Emerald Isle. The eHealth Ireland Committee and a governance model for its eco-system will be in place before the spring is in full swing, and processes are in place for requisite law and policy to facilitate the healthcare system truly becoming a digital option. A strategy and the operating model are also in place and enthusiasm for what is eHealth beginning to grow.