15 June 2020

The ugly truth about disasters and digital health

COVID-19 Policy Technology Telehealth

COVID-19 is the most important event in decades for showcasing just how effective the digital health sector can be for solving major issues in our healthcare system, and just how good we are at solving issues when we really need to.

Some of the steps we have taken for COVID-19, such as telehealth, will almost certainly not be significantly wound back. So if there is going to be a downside, it is going to be what we do, or not do with these great leaps forward.

Here’s six reasons things will never go back to the way they were in digital health, and how we could still manage to squander this opportunity if we’re not careful.

1. Telehealth

As important and obvious as the decision to introduce telehealth to general practice across the spectrum of MBS items seems now, word is that the decision was still a near thing at the time. The government was backed into a corner in letting this genie out of the bottle and it was some nifty last-minute lobbying from certain highly placed individuals that eventually got it over the line.

Some sense of how fearful the government was of the so-called “woodwork” effect of telehealth (in that everyone comes out to claim for anything), is the $600 million that various government representatives promised to add to MBS spend to cover the impact. That the MBS initially didn’t move at all into overspend, and when it did, it only increased by $100 million in the worst month of the pandemic, was unexpected by the government.

Telehealth is by no means perfect. But it rapidly solved so many issues and introduced both GPs and patients to such an obvious system efficiency that it can’t be reversed now.

However, it does have to be sensibly managed to avoid serious issues developing. The government is said to be keen on keeping, but only as an audio-visual consult, which is not only impractical, but wholly missing the point. For all the audio calls that were done in April that helped create most of the $200 million in MBS telehealth costs, many were efficient and necessary, and many weren’t. But the phone, and in the future even simpler patient-doctor communication channels, are clearly efficient if you put the right price on a call and do things like make those calls, as much as possible, occur with a patient’s regular GP. We could still, with not much effort, make a mess of telehealth. It should be a priority to work it out and telegraph those changes well before the September deadline.

2. Privacy and data security

Research out of the UK suggests that nearly 30% of people are now more inclined to share their health data with government than prior to COVID-19. Before it lost most of its mojo to the “flattened” curve, the COVIDSafe app was downloaded by more than 6 million Australians. And whether doctors or patients realised it, most state governments authorised non-secure data exchange of script information, and other patient data, in order to make COVID-19 isolation ends meet. The upshot is that there has been some shift in community and health sector sentiment towards health data privacy and sharing.

That progress is potentially only one idiotic data breach away from being almost fully reversed, so we need to treat this privileged position with the care it deserves. But be practical. It is interesting to also note that where state governments did not authorise sharing of script data via workarounds, such as taking photos of bar codes and emailing them to pharmacists, GPs in their thousands flouted the rules anyway in order to help their patients out of a bind. There are some lessons here in how strictly we have been adhering to things such as secure messaging protocols when, in some circumstances, there may be far easier ways to solve what we thought were complex issues.

3. Government

Government by its nature needs to have process and regulation, and it will always be driven by politics at the top. So, we aren’t likely to see spectacular implementations of new technology, including private-government partnership contracts in order to make things move. But there will be some substantive upside legacy from what COVID-19 taught the government:

  • Most governments, federal and state, are no longer as afraid of the cloud as they were prior to COVID-19. In the face of the need to scale up at speed, with low cost and high impact, government turned to cloud-based applications and vendors to solve a lot of its problems. That is going to change the momentum of the digital health sector significantly in the next few years.
  • Healthcare technology vendors saw a government sector they probably did not realise existed: one that, when it needs to be, can be awesomely kickass and efficient. With that secret out, the pressure is going to be on all governments to live up to some of the new expectations they have set. They can’t be as wild as they were during a pandemic in getting stuff done, but they also can’t hide behind all the excuses they have previously used on vendors and public lobbying groups for decades anymore.
  • COVID-19 has seen a spate of highly effective and innovative public-private partnerships that are likely to show the way for more of the same. Barriers have been broken down.
  • There is a renewed faith in the ability of government. It’s a faith that government needs to realise is an emotional bank account that it can’t squander by going back to all the old ways. Government needs to adapt to what it learnt quickly and invest wisely some of that emotional capital it’s now earned.

4. Perceptions of ‘interoperability’

If COVID-19 changed only one thing for digital health, then showing up how we may have twisted ourselves in knots for decades over the issues and complexities of sharing health data, for the wrong reasons, might the most important revelation.

If you take the HIMSS definition of interoperability, and cast it across all the problems we solved rapidly because we needed to, when we couldn’t do it for decades prior, you tend to look at the problem of interoperability in a different light.

Interoperability is the ability of different information systems, devices and applications (“systems”) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organisational, regional and national boundaries, to provide timely and seamless portability of information and optimise the health of individuals and populations.

When push came to shove in COVID-19, years of attempting to solve “secure messaging”, of big global vendors “blocking” sharing to varying degrees and of regulatory requirements for certain standards of privacy protection, meant just about nought. We went around just about all of it in all sorts of ways, which at once raised eyebrows about contravening traditional standards and thinking, and then posed questions on whether there might be a more-practical middle ground on some of these once seemingly intractable issues.

One question that was raised prior to COVID-19, but now should be firmly on the agenda of those in charge of improving healthcare interoperability, is: why are we so obsessed with sorting out secure messaging as a first step to better interoperability? Should we have a more holistic and practical approach that takes all the lessons from this pandemic and applies them at a higher level of thinking?

As a side note to that, should the ADHA ditch its seven pillar strategy (pillars 1 and 2 being the My Health Record, and Secure Messaging) and adopt just one pillar – interoperability (which happens to be pillar 3) – to which it can apply all the practical lessons about interoperability from COVID-19?

5. The cloud

If you happen to be a medical software vendor and you’re over hearing about the cloud and how you will need to move with the times, when really not that much has happened so far, and you’re getting a little deaf to what could easily be regarded as another boy crying wolf, then you need to realised the wolf is real and it’s here. And there is a lot in the open paddock to for it to eat.

The government now sees what the cloud means to healthcare, has tasted it, and wants more where it came from. Increasingly, cloud applicability and integration is going to be the norm  because the government is finally moving on the cloud, and it is specifying its use in its contracts.

There is also overwhelming pressure starting to build on legacy healthcare systems, one of them being the desktop patient management systems of most GPs, via surrounding health apps that are integrating to these systems to a point where the line between the functionality of the core system and the cloud integrator (HotDoc, HealthEngine, et al) is getting blurry. If the major patient management systems don’t move now, something is going to give.

One thing likely holding this particular niche of the software market back is the corporates, none of whom is in a good enough cashflow position to fund the migration of its system. But with both government and private players at their heels for change, things are going to start changing.

The irony might be that government may lead the cloud revolution in healthcare. During COVID-19 it negotiated several contracts with private cloud-based vendors which were groundbreaking, and which were surely an omen for other system vendors.

A good example is the contract that cloud patient management system vendor MediRecords landed with government-based health information and triage provider Healthdirect. From the inside (your author is anon-executive director of MediRecords) the story of this contract and what it achieved for government within such a short space of time is eye opening.

When COVID-19 hit Healthdirect had a huge problem. Its call centre was immediately overwhelmed, and it was running technology that couldn’t scale up. How could the group, literally within days, expand its service by adding thousands more “seats” which would direct users to geo-located, appropriately qualified professionals? And how could it do this with a real time system that was coordinating and sharing data and notes across Australia in hundreds of locations, so it could respond to any patterns that were emerging?

the answer was a combination of the MediRecords cloud suite and Amazon Connect functionality. The contract was negotiated and the products adapted and integrated within days. It worked on day one. The adapted solution is now being rolled out for other providers and Healthdirect is considering using the scaling technology for other services it provides.

6. Patients

Patients have changed. They love the utility of telehealth. They like that their doctor writes them a prescription either in clinic or on the phone and it somehow gets delivered the next day. They don’t mind the government tracking their movements in the name of better health. They feel the government is doing a pretty good job with healthcare overall based on the management of COVID-19. They’d love to do more digital interactions with their doctors right now.

How long are we going to have patients in this forward-leaning mood? It’s hard to tell, but in all our plans we should be taking this new headspace into account and leveraging it to the best of our ability.

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