28 June 2019

Two diverging health worlds – with no bridge between

KnowCents Technology

Tim Blake has been at the bleeding edge of digital health consulting for quite a while. His CV includes working with PwC, Oracle, SAP, as the CIO of Tasmania’s Department of Health and Human Services, as a board member of HL7 Australia, and consulting gigs with NEHTA, the federal Department of Health, and the Australian Digital Health Agency.

For someone who has spent much of his time with big C-type consultants and government, he is entirely what you wouldn’t expect, in that he’s still young, energetic, excited about his work and, most of all, a bit out there.

He’s one of a few people I know whom I might classify as an evangelist for enabling technologies, such as open APIs, FHIR and the cloud, as well as for the concept of engaged patients and innovative, digitally-enabled models of care.

And he is squarely thinking “patient first”, which a lot of people say they are doing, but actually aren’t.

Blake’s penchant for the bleeding edge and transformation, aren’t how most people with such an impressive resume would position themselves if they just wanted to garner the maximum amount of highly paid work. He’d stay conservative, if he was pursuing that. Instead, Blake is pursuing something quite different: real change. Some would characterise Tim’s aspirations as unrealistic in the context of our current set up in Australia.

More than anyone else I know, Blake has lived in the two currently diverging universes of digital healthcare: an old world that is linear, relatively stable and offers the safety of the known in the risky world of providing healthcare, and, an unstable new world, which is simultaneously quivering with huge untapped opportunity and uncertainty.

The uncertainty stems from the risk of destabilising a complex system with significant immunity to change, to move healthcare into a potentially revolutionary, connected and information-supported system. The new world could signal transformational change in safety, quality, efficiency and sustainability, and, the eventual end of the stable old world.

The old universe is largely understood, for time being at least, but very poorly connected, and trailing most other societal sectors in terms of digital transformation. Many in Australia are finding it a hard place to leave.

The new world of connected and distributed information, sharing meaningful healthcare data in real time, especially with patients, might make everything operate far more efficiently and safely.

It’s not there yet, but our digital and social ecosystem is shifting rapidly in favour of this technical environment, and for the first time in many years this pressure is causing cracks in the old world system.

This might happen with or without government involvement, and with or without the major current healthcare providers operating in Australia, if they don’t wish to participate.

Adding pressure and momentum to this shift is the new focus on healthcare from the massive global distribution platforms – Apple, Google, Amazon and Microsoft. With apologies to Professor Scott Galloway of The New York University Leonard N. Stern School of Business, you might call these companies “the four horseman of a potentially fast approaching digital healthcare apocalypse”, threatening to tear apart those which choose to ignore the transformative potential of these technologies.

If you take as a precedent what “digital” has done in sectors such as retailing, financial services and marketing, many current healthcare services might get left behind.

When asked if he thinks the reality of digital health technologies such as wearables, mobile health apps, FHIR, artificial intelligence, augmented reality, et cetera, might not live up to the current hype, Blake is highly pragmatic.

“We’re at the peak of the hype cycle for many of these technologies, so, of course, there are going to be some disappointments as things find their appropriate context”, he tells The Medical Republic.

“All of these technologies are necessary, and have important roles to play in improving healthcare delivery. But none of them are, on their own, sufficient to bring about the change that we need to see,” he says.

“These digital health technologies have to be applied in careful and intentional ways, creating new digitally-enabled models of care that take into account existing clinical culture, workflows, funding models and other challenging contextual factors.”

Blake says that it’s OK to take our time and get the design of these models of care right. But at the same time, with a health system here that is largely publicly funded, the risk is that health provider organisations are being too conservative, underestimating the power of the engaged patient, and missing some of the key opportunities created through technology.

“We risk missing enormous opportunity in Australia because there is currently no clear mechanism or trigger for our government to move on change.

“We remain stuck in what are largely Victorian-era models of care.”

He doesn’t think a lack of change is simply an absence of strong leadership.

“There is a lack of courageous leadership in policy in healthcare, but the bigger issue is a deeply embedded culture that is actively resistant to change.

“While there is plenty of digital health innovation in Australia, much of it gets stuck in startup ‘accelerators’ or in seemingly endless pilots, with no clear path to achieve scale or commercialisation,” he says.

Too many times I’ve seen the system work against innovation to ensure that it isn’t successful, and that the status quo is maintained. In that environment, it can be hard to build the evidence for change.”

Blake points to some very senior government digital health executives who in his words do “get it”, understanding the need for change and some of the ways it might be achieved. But he thinks that many of them are constrained by the system, toeing the line on government policy, unable to say what they really think, and doing their best within their old, linear world to progress a digital health agenda.

Is it a matter of our health system isn’t really broke so don’t bloody well try to fix it, I ask?

“That’s an interesting question,” Blake notes.  “We seem to have this strange cognitive dissonance on this topic. Most people think the system is broken, but it’s other people that need to change what they are doing, not me.”

When I ask Blake if he sees two diverging healthcare universes in Australia – one in the new world and one in the old – that don’t seem to have much of bridge between them, he smiles.

“That’s certainly a risk. I’m definitely starting to interact less and less with the traditional, change-resistant parts of the health system, because it’s just too hard and frustrating to get things done.”

But how do you get anything done without having some sort of integration into the national infrastructure which is determined by the government and the likes of the ADHA? If you aren’t tapping into their infrastructure for things like secure messaging, the My Health Record, and the like, does that risk being disconnected over time?

“Look, it’s definitely important to integrate with these key pieces of infrastructure,” says Blake.

“We all need the My Health Record and secure messaging to be successful, and I will do everything I can to help make them successful. But they’re only foundations. They are necessary but not sufficient to deliver significantly improved health outcomes for patients. To do that we need the innovation that comes with digital health and digitally-enabled, intentionally designed models of care.

“And when it comes to these things, we just can’t afford to wait for government to get it. We’re moving ahead without them.”

One of Blake’s current projects is possibly a good example of this.

He is working with Primary Health Network commissioned health service to develop a “social prescribing” solution for patients with chronic disease living in rural and regional areas. This shared-care planning solution allows health providers to work with patients to codesign a care plan with psychosocial goals, aimed at addressing the root causes of chronic disease.

For example, patients struggling with obesity may have deeper issues of social isolation and untreated mental health issues. By identifying goals that address these underlying issues, patients can undertake various actions that improve a range of outcomes, including their health. These actions could include volunteering, club membership or other social activities to target isolation, or to improve financial or health literacy.

It is a concept that has gained significant traction overseas, particularly in the United Kingtdom, where National Health Service GPs are using some of these elements to improve primary care health outcomes.

However, such an application may struggle in the current environment in Australia to find traction, no matter how sensible and practical it is. GPs are paid mainly on a fee-for-service basis, are time poor, and, other than for a few related MBS items, there isn’t much on the social side that the government will actually fund.

Ironically, it’s innovation which talks directly to the government’s stated goals in health – lower costs all around, more efficiency, social good and interoperability – but which doesn’t fit into any current funding framework.

So, is Blake disheartened at all by where a project like this finds itself in today’s local digital health ecosystem?

“Work like this is laying the groundwork for what will almost certainly one day be an integral part of the system,” he says.

While pragmatic about where the system is currently, he says the significant momentum for digital health technologies in both the US and Europe means that it won’t be long before the Australian government is pressured to move faster. He points to the recent proposal by the US government to mandate FHIR as an interoperability standard that all providers and tech vendors need to start using in that country.

The other potential block for work like this is the current funding set up in Australia, which from a primary care perspective is still weighted heavily to fee for service, rather than outcomes.

Blake is optimistic that in time, this will change.

“Health systems across the world are gradually moving towards value-based care models that are more equitable and sustainable than our current approach to funding.

“What we haven’t yet fully grasped in Australia is that value-based healthcare needs digital health technology to make it work. Whether it is FHIR for improved interoperability, or patient-reported outcomes to understand the patient’s perspective on a health intervention, we need digital health as a vital component of our future health system.

“That future is coming towards us fast.”