Health is a digital laggard – a diagnosis and treatment plan

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Picture: Digital economy consultant Ernie Newman

Guest column by digital economy consultant Ernie Newman

A shared national vision is needed to change a broken health system designed for past centuries into a customer service oriented one that draws on the technology of the digital era.

Our health system is broken. The customer interface was designed for the 19th and 20th centuries and needs a complete re-engineering to take advantage of the revolutionary new opportunities of the digital era.

We need to start with a new vision – not just of the health IT structures, but of a customer service model enabling people to interact with health services using the vast capabilities of 21st century technology. That requires consumers to take charge of the agenda, with the active support of the health IT sector, clinicians, minister and government.

A broken system

If the New Zealand public health service delivery system presented for medical treatment it would be sent straight to palliative care. It has suffered through years of neglect and lack of preventive treatment and its complaints have been swept under the carpet.

It is suffering from long-term malnutrition, fed at a level barely capable of sustaining life. The symptoms are everywhere – crumbling buildings, a demoralised workforce, people dying on waiting lists, endless apologies in the media and an environment where every thinking person with the financial resource opts out by paying for private health insurance. Yet rather than focus on a cure, its caregivers have made great efforts to cover up the symptoms.

Meanwhile the environment is getting more challenging by the day. Our aging population is placing unprecedented demands on the sector and the tsunami is beginning, not ending. Our population is increasing at an unprecedented rate through net immigration – so much so that we have nowhere near enough safe and healthy homes to shelter people. That’s leading to illness and even more stress on the system.

Medical science has developed to the point where people can be kept alive just about indefinitely if cost is no object, and the public have an unrealistic expectation to receive the benefits as of right.

Health professionals are aging too. We must get more from less. And yet there is professional resistance to any reallocation of responsibilities down the stack – from doctors to nurses, nurses to pharmacists and so on.

The digital opportunity

Among the challenges there is a shining light. The digital era has opened opportunities across society to make services of all kinds much more open to modernisation, automation and consumer self-service. Nearly every sector has embraced this and re-engineered its customer interface from the start of the digital era, taking the view of a customer looking in rather than a service provider looking out.

Not so in health. Against the odds, many highly competent and committed people have delivered some highly successful health IT initiatives. But they’ve done it in an uncoordinated and random way. There’s been no clear destination for the health IT system or the 21st century structure of health services.

Efforts to coordinate IT systems from bases developed by district health boards meeting their needs in isolation have resulted in tensions between local, regional and national imperatives that are almost beyond resolution, especially in the absence of an overarching vision of the future state–customer interface we are trying to achieve.

Health IT has been like solving a 1000-piece jigsaw without access to the picture on the lid, and without knowing whether the pieces constitute the same puzzle or are a mixture of 100 pieces from 10 boxes. Again, absent a vision, we are decades behind and, despite the dedication of many good people, we’re falling further behind by the day.

Why is health failing to make progress?

Health service delivery and funding is a system of mind-boggling complexity. A mixture of public and private sectors, with a labyrinth of cross-subsidies, interactions and processes dating back to the time when the medicine man was the wisest and most revered person in the village.

Doctors today still hold that status in society, rightly so when it comes to the practice of medicine, but perhaps wrongly so when it comes to fronting the evolution of the customer interface, structure and funding of a 21st century health system. Clinical caution is admirable when they are wielding the scalpel, but when they are holding the key to the next generation of funding and service delivery it can quickly turn to ultra-conservatism, change resistance and patch protection.

Clinicians still refer to us as ‘patients’ – a term that implies subservience, rather than adopting a more neutral term like ‘customer’. Clinicians, in my observation, genuinely believe they know what we as customers need better than we ourselves know.

Most sectors have fully embraced interconnecting databases. Not so health. Even with the new Manage My Health patient portals, and despite the common link of a unique NHI number, updating my address doesn’t flow through between my primary practice and the local hospital a kilometre away.

Today’s health consumers have an array of digital tools available to self-manage their health through personal digital devices, internet advice and self-assessment tools. Commonly, customers have self-diagnosed by the time they present to a practitioner and have a fair idea of the required treatment path. They seek affirmation, or otherwise, and a course of treatment they have already mapped out. In many cases, they should not require a face-to-face visit to a GP. Delegation down the stack, a virtual consultation or a mix of the two would be effective and resource saving.

A high percentage of consumers also have access to new communication tools such as video. Video has been proven to have a huge potential in some health services, for example, mental health and addiction, where there is no requirement for a physical examination, and in circumstances where, because of isolation, the customer would otherwise not seek treatment. There have been numerous trials of video or telehealth in parts of New Zealand. Most have succeeded, yet few, if any, have reached anywhere near their potential in terms of scale.

Three enormous roadblocks

First, complexity. The system is so complex and convoluted that everyone is terrified to tinker for fear of unintended consequences. We have a Ministry that takes eye-watering sums of money from taxpayers that it redistributes through 20 DHBs, multiple PHOs, primary practices, allied health services, NGOs and more. It’s a 19th-century structure completely unfit for purpose in a 21st-century digital environment with the new dimension of customer self-service.

Second, lack of leadership. Sadly, recent health ministers (I’ll exclude the current Minister David Clark as he arguably hasn’t had time to make his mark) have been totally preoccupied with shutting down the debate we desperately need about the shape of services in the future. Their goal has been to keep health off the front page at a time when that is precisely where it needs to be. Of the services governments provide, health stands alone as the most broken and most in need of fundamental redesign. The Ministry focuses on eternally transforming its own internal structure, diverting its attention from the far more pressing and challenging imperative – where the real rewards lie – of transforming the whole sector.

Third, the lack of input to the debate by customers or consumers. Most sectors at least go through the motions of asking customers what they want. Airlines, for example, put huge focus on qualitative and quantitative research before deciding on a new route to service. Sure, they ask their pilots for input, but they wouldn’t assume that the pilots speak on behalf of the customers.

A national vision

So what needs to happen? In my opinion the starting point must be a shared national vision of the health system we want in 2030.

The vision should be led by a consumer action group comprising well-informed consumers, with liberal consultation with the multiple sub-groups that constitute the health system’s customer base. It should be supported by access to clinical and technology people. It should work collaboratively with government but not be dominated by government – leaving it all to the government has failed.

This is the moment for the needs of customers to be determined by themselves, rather than have the supply side of the industry decide in isolation what the demand side wants. The consumer action group’s terms of reference should stipulate that it is not to be constrained by today’s system. The migration path is out of scope at this stage and can be developed later. However, the group needs to be realistic in recognising that health is a sector where there will never be enough money, so the focus should be on devising a customer interface that delivers more with less.

We already know quite a few things about what consumers want. For example, earlier work by the National Health IT Board showed that consumers welcome the consolidation of their health data onto a single electronic file and in many cases have assumed that has been happening for years. They do want assurances about privacy, especially where sensitive conditions such as sexual or mental health are involved or where individuals are sensitive about being traced, but that is achievable.

We know that telehealth or video consultations work in a wide range of settings and can represent a cost-effective solution for people in isolated places. We know that nurses and pharmacists are well trained, highly skilled professionals, trusted by consumers and capable of working at a level significantly higher than they are currently assigned. So we have a solid base of information and insight.

The task of the consumer action group would be to flesh that out into a consumer-centric health service delivery model that will serve well into the 21st century. It would look at the respective roles of general practice, hospitals, pharmacies and allied health services. It would consider the utility of digital communication tools such as video, email and social media. It would assess a future model of support for our aging population, including aging in the community, funding models and personal health records. Out of all that, it would articulate a vision of the fit-for-purpose health service interface that consumers would like to see.

Once such a national vision was adopted, every new service and IT initiative could be tested against it. The route from the current state to the new utopia, and the timetable, can then be plotted and the budgets drawn up.

The goal

The rewards will be immense. We have a robust health IT industry that will blossom once the destination becomes clearer. New Zealanders will have the kind of health services to which we aspire. Unnecessary bureaucracy will be exposed and dismantled, and resources put back into patient services instead of being swallowed up on an obsolete money-go-round.

My challenge to the health IT profession is this. Put your weight behind supporting a consumer action group tasked with envisioning a re-engineered health customer interface that reflects the changed needs of today’s society and the massive potential of the digital age.

Ernie Newman is a digital economy consultant based in Whakatane. This column is taken from his presentation to the ITx Conference in Wellington on 11 July 2018.

If want to get in contact, email Ernie Newman

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