26 April 2021

Why the UK and US are now in front of us in digital health

Comment Telehealth

If you ask virtually any senior digital health staffer in any advanced country what was the greatest leap forward that COVID induced in their healthcare set-up, the inevitable answer is telehealth.

In the UK, the US and Australia, telehealth made leaps of various sizes, often associated with governments accepting that they needed to establish pay signals in the system for it to be used more effectively.

But while vastly applicable and useful in the crisis, the telehealth story in some ways belies what COVID really did in many countries: to put their existing interoperability infrastructures to the ultimate test.

In last week’s Wild Health Webinar, digital health leaders from the US, the UK and Australia were asked what COVID-induced innovations were significant and real, and which ones were more potentially illusionary. Which ones might slowly slide backwards despite the hype?

As expected, telehealth was an initial winner nominated for each country. Notably in the UK, video telehealth took off, whereas in Australia video has not taken off at all. It feels likely that video telehealth was able to take off because of existing or developing infrastructure in that country, especially around delivery of hospital outpatient services.

Three years ago, the UK moved to put all its health service providers and vendors on notice that the intention moving forward from that point was “cloud first”.  The NHS put a lot of detail around what they were expecting. It wasn’t a new standard (the route taken by the US) but it might have been as good as. If as provider you were going to dawdle and not upgrade towards new web-sharing technologies you would be in trouble. As a vendor, there was nothing to do but start developing systems that met the criteria.

By the time the COVID pandemic hit, NHS cloud-based solutions such as Carenotes allowed staff to view and share patient medical records from a desktop or mobile device anywhere in the UK.

Before the pandemic, a lot of the cloud-infrastructure-based solutions were in testing mode. But when the pandemic hit, much of that work was switched immediately into operational mode so that staff could make faster, better-informed decisions.

According to Professor George Crooks OBE, chief executive of the Digital Health & Care Innovation Centre in the UK, what COVID did was change long-entrenched attitudes of providers towards information sharing, in particular with patients.

“The major step forward [was] moving forward with an ICT architecture that is cloud based and distributed, and allows us now to blend citizen-generated data with formal healthcare-generated data and allow that data to flow seamlessly,” Professor Crooks told Wild Health.

Professor Crooks said that prior to COVID, the cloud-based infrastructure that the government was pushing and putting in place was resisted by professional groups, but the pandemic meant there were few excuses not to use what was in place.

One immediate use of systems being tested was contract tracing. Because the cloud infrastructure was already established, the government could quickly switch on a new application, allowing citizens to participate in the contact-tracing process.

“The beauty is that it puts the citizens at the centre; they do their own contact tracing,” said Professor Crooks.

“And the average time from getting a positive notification to an individual starting self-contact tracing is 12 minutes,” he said. “And 55-60% of citizens actually actively participate within an hour-and-a-half of that notification.”

The pandemic in the US saw the benefit of 10 years of policy work around information blocking come to the fore during COVID, much like the UK saw its cloud first positioning, and the development of some centralised services based on distributed cloud architectures yield data sharing that resulted in significant impact in the immediate issues presented by COVID for government health services.

When the pandemic hit in the US, providers and vendors were already four years into a five-year regulatory deadline that said if their systems weren’t interoperable to a certain standard – which included that everything had to have a Fast Healthcare Interoperable Resources (FHIR) interface to promote such sharing – then their system or product might be deemed as “unlawful” and attract significant penalties.

Although the US is a vastly eclectic mosaic of private, public, state and federal systems, when COVID hit, it was a test of how far the legislation had pushed everyone in the system to align in terms of better data sharing in the system, and importantly, in terms of providing patients much better access to their own data.

The US approach has been quite different from the UK’s, probably due to how fragmented and messed up the US healthcare system has become under an array of state, private and federal funding regimes, dominated by the private “managed care” insurance providers.

With so much mess, the US decided they needed to facilitate change by establishing nation-wide standards that demanded every provider and vendor get their act together on the ability of their services and systems to share patient data.

The government introduced “anti-information blocking” legislation and gave everyone five years to get ready. In the meantime, they did a lot of communicating, and nursing of the more backward of the providers and vendors.

To get ready, vendors big and small had to alter their products to make them widely accessible and connectable to everything else in the system.

Providers had to do the same thing.

No longer was the government going to tolerate a patient being on a big globally branded EMR in one hospital, and that patient couldn’t travel across the road to another hospital with the same brand of EMR because both the vendor, and the provider, were benefiting commercially from the patient’s data not being able to travel across that road.

What is apparent in the UK and the US is that their change in approach to their digital health interoperability issues 3-5 years ago gave them a lot more agility and power to engage meaningfully with patients during the pandemic.

While the UK government did take on the establishment of much of its own infrastructure, it also encouraged all providers and vendors to move rapidly to open and distributed systems architectures and the cloud. It set up units to help providers and vendors so there would be some alignment in what they were doing.

What is now apparent in Australia is that although we ended up managing the initial phases of the crisis better than both the US and the UK, our digital health infrastructure had very little, if anything, to do with it.

The My Health Record, which should have been the centrepiece of a crisis such as COVID if it was ever going to live up to the government’s promises, was almost entirely missing in action.

Unfortunately, Australia’s digital health infrastructure is  “very solution focused, very insular in the way it’s conceived”, Grahame Grieve, the founder of FHIR, told the Webinar.

“Instead of building an infrastructure that leads to new integrated market development, it seems that we’ve headed towards an infrastructure that sucks everything into what it is,” he said.

“It’s very frustrating to see how that approach isn’t developing into, what I think we need, which is a resilient and adaptable architecture.”

The best that we could manage in Australia was expediting a program for electronic script writing, a program that was initially going to take a year, and we managed to get up in a raw working form in about three months.

Ironically, this program, which is yet to be fully implemented, is a case of cloud-based-and-distributed architecture in the system. But it has virtually nothing to do with our supposed backbone project of the My Health Record.

If you read between the lines on the Wild Health webinar, which looked at COVID-induced digital health innovation between the UK, the US and Australia, the single biggest message is that Australia is stuck in the past as far as digital health is concerned.

Such a view might come as a surprise to most of our politicians, who don’t really understand the basics, but, ironically, have been given the My Health Record to point to as just how great progress has been in Australia.

While there was much in place to facilitate much better interoperability in the US and the UK systems when COVID hit, there simply wasn’t in Australia.

If it was meant to be the My Health Record, then what COVID demonstrated probably once and for all was that this project is an interoperability dead end for the country.

We need to back up, check out in more detail what other countries are doing with modern distributed and open systems, and rethink our approach.

Part of that approach should probably also take note of both the US and the UK, which as base did not try to dictate technology or systems but gave the market context and direction, in the case of the US via an enforced standard, and in the case of the UK, at least by notice to everyone in the system that they should be hubbing around cloud, and then setting up support services to help align providers and vendors.

Both the UK and the US in varying degrees announced and dictated the future for vendors and providers, via some sort of standard setting, and then made sure they gave everyone the time and support to make the transition.

In some ways, our government’s persistence now with the My Health Record is laziness brought about by a feeling that things are OK. That we managed the pandemic better than anyone else, and our health system is largely better than anyone else’s.

Both things are true.

But it’s a stark reality that our digital health policy and infrastructure are backwards now and fast starting to hold back the potential of our whole healthcare system.

It’s patients that will bear the brunt of this lazy approach in the end.

It’s a climate-change-like problem for Australian policy makers.

It’s difficult to see today, and there is a lot of politics resisting changing our current settings.

But like climate change, a weak digital health infrastructure and leadership from government is going to blow up in our faces sooner or later. Probably in a big way.

You can watch the Wild Health Webinar on which the ideas in this article are based HERE.

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Dr. I. Rivlin
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Dr. I. Rivlin
15 days 10 hours ago
We should all read E.M. Forster’s dystopian novella “The Machine Stops”. Even though written in 1909, the author presaged a time in the future when dependence on automation was such that humanity could hardly do anything for itself. Then one day – the machine stopped… (leaving everyone high and dry). We are idiots if we can’t see that one day, the machine *will* stop and a veritable apocalypse will ensue. Those who want to cede their lives to a machine show very little imagination. Computers are sometimes labour saving devices and often nothing more than a royal pain. I would… Read more »
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