Creating our future Health Ecosystem
The concept of an electronic health record has existed for decades, the technology is ready, the need is clear, the desire is there, yet despite all this there are very few success stories. A nationwide electronic health record remains an elusive goal that few countries have achieved.
Now everything has changed, in 2021 the world is a very different place to what we imagined a year ago. Peoples’ attitudes have changed, our use of technology has changed, and the need for a united healthcare system has changed. The barriers that have held back the success of an electronic health record have begun to lift.
In the news recently was Southern Cross’ launch of their CareHQ app, which enables New Zealanders to immediately see a GP for a telehealth consultation, using their mobile device. Pre-Covid that could have become a white elephant through lack of trust and comfort; today it makes perfect sense and is poised to enable a new level of access to healthcare for New Zealand.
The biggest change of all though is the Ministry of Health’s vision for how an electronic health record should be, and that is that it shouldn’t be an electronic health record at all. The Ministry has seen the future of connected health, and it isn’t a centralised record of a patient, it is an open ecosystem of information about the wellbeing of people. This new vision not only lifts the barriers, it has the potential to smash them.
The national Health Information Platform isn’t an electronic health record, it is a decentralised wellbeing ecosystem that encourages innovation and participation. It is a truly Kiwi concept that embraces the entrepreneurial and collaborative spirit of New Zealand.
Introduction
New Zealand has everything it takes to have the most connected health system in the world: an absence of state Governments, a small population, a first-world economy, and a unique focus on wellbeing. Yet despite these favourable factors, as a nation we suffer from a fragmented and siloed health system.
New Zealand is a collection of small islands remote from the rest of the world, this is a perfect analogy for our healthcare data. This is not news to anyone, those within our healthcare sector are aware of the challenges of getting accurate and timely access to information. Consumers of our healthcare system are impacted by this every day.
Past efforts have been made to overcome this, to connect the healthcare sector by creating a single unified view of the patient, a single electronic health record. The concept of a central electronic health record has merit at face value, but has struggled to be successful, both in New Zealand and around the world.
A Fresh Approach — The Wellbeing Ecosystem
New Zealand’s culture is one of collaboration, connectedness, innovation and most importantly of individualism. We are a nation of many nations and cultures, to steal a line from a New Zealand song, we are a melting-pot of people. Our culture doesn’t fit well with a centralised monolithic system that treats everyone the same. Such a system either becomes so complex in an attempt to cater to the needs of all New Zealanders, or it only serves the needs of the many and overlooks the needs of the few who need it most.
Our healthcare system should reflect New Zealand’s unique culture, rather than being a single system, it should be a connected ecosystem of information and services that enables innovation and individualism. An ecosystem that puts the human at the centre, and from there spawns a connected tree of information that can branch to suit the unique needs of every different person.
This does not mean a continuation of the silos we have today. Today’s silos are islands of duplicated systems capturing the same data in the same way, but disconnected from each other. Today’s silos do not enable individualism as they are all the same, they are simply unconnected islands of data.
Tomorrow’s connected ecosystem of wellbeing information not only connects these islands, it enables unique views of every individual, it enables new providers to offer personalised services, it enables a system-wide view to identify underserved areas that need focus. Most importantly it enables people to actively participate in their own wellbeing by being better informed about their health, their options, and the impact of the choices they make.
The Health Information Platform
Enter the Health Information Platform, the heart of the new wellbeing ecosystem, and the right concept to connect New Zealand’s healthcare information.
Rather than being a monolithic system that stores all health records in one place, it is an ecosystem that connects the data to the people, be they consumers, providers, policy makers or innovators. This would allow for a diverse ecosystem, and yet one single source of truth.
The national Health Information Platform isn’t an electronic health record, it is a decentralised wellbeing ecosystem that encourages innovation and participation. It is a truly Kiwi concept that embraces the entrepreneurial and collaborative spirit of New Zealand.
Barriers to Adoption
The challenge that stands before the Ministry and the Health Information Platform is not a technical one, the technology needed to create the ecosystem already exists, the challenge is a very human one. Adoption of the system by consumers, providers and developers is the single biggest challenge, and the most common reason for failure of these initiatives.
Although the Health Information Platform is taking a different approach to a traditional EHR (Electronic Health Record), the same barriers to adoption that have held back EHRs will be faced by the Health Information Platform.
These barriers are, in order of impact:
- Trust — the reluctance of consumers to have their information stored centrally and accessible to all, drives a concern about what it will be used for, driven by a lack of transparency. Conversely the increase in transparency leads providers to fear a loss of IP and exposure for missed or incorrect diagnosis.
- Cost — difficulty of measuring direct impact can make justifying ROI a challenge. Full blown EHRs have traditionally come at a very high cost, not just the technology cost but the cost of change and adoption.
- Inertia — to be most effective, changes to processes/procedures are needed, simply digitising the old way of working won’t deliver the intended outcomes. Getting the healthcare profession to change proven ways of working isn’t easy.
- Poor User Experience — many EHR systems are aimed at medical professionals, and have a focus on completeness of detail rather than ease of use. They are often based on older technologies that struggle to provide a modern user experience. This presents too much of a learning barrier for new users.
- Lack of Interoperability — Designed as closed, self-sufficient systems EHRs are difficult to integrate, and where integration is available it is often in complex health data standards that limit the ability to connect with non-health data sources. Conversely legacy system across the sector have limited integration ability.
- Motivation and Value — related to cost, but a separate challenge is the perception of limited value from these initiatives with results in a reluctance for providers, developers and the market to engage. For all these potential barriers, it goes without saying, that a watertight privacy model and associated governance will be vital.
“Despite the barriers that have held back the adoption of electronic health records, we strongly believe that the approach taken by the national Health Information Platform is the right one to overcome these barriers. The national Health Information Platform isn’t an electronic health record, it is an ecosystem, a marketplace, a greenhouse to foster innovation in New Zealand.”
Mike Bullock — Associate Director, Datacom
Keys to Success
This new ecosystem approach has the potential to succeed, to ensure it does succeed there are key areas that will need to be addressed:
- Human Focus — it is vital that the human is the focus of everything, not the “patient”, the user, or the consumer. By taking a human centric view we extend the thinking to a wider wellbeing perspective. If we can use the Health Information Platform to improve wellbeing we may be able to avoid people becoming patients in the first place. Creating a system to fix people that are already in need of healthcare is starting in the wrong place.
- Open — this doesn’t just mean open standards and APIs, it means open to anyone to participate in, be they a startup, multinational, or NGO. The barriers to participation need to be as low as possible. There is also a need for transparency to ensure that it is clear who is involved, what they are doing with the data, and what their motivations for participation are (commercial, financial or altruistic).
- Self Governance — every participant, be they a consumer, provider or developer needs to have control over the information that pertains to them. This is not just about consumers having control over their personal health data, but also providers having control over their diagnosis IP, and developers having control to step in and out at will.
- Active — the creation of an ecosystem to simply store, connect and share health information is a great step in the right direction, but the ecosystem needs to go further. It should be an active participant itself, using the information it holds to provide insight from the data. The more data added to the ecosystem, the greater the value it can provide through insights. The ecosystem needs to be active in helping consumers and providers make informed decisions.
- New Zealand Aware — New Zealand’s culture has unique concepts such as Whanau that don’t translate directly into western models. An example is in the case of delegation of access to data, a western system may enable immediate family to act on behalf of a patient, but it is important that the system is aware of the concept of Whanau and offer the ability to delegate outside of the concept of immediate family.
- Accessible — this doesn’t simply mean an accessible UI, it means accessible for people who may not have access to technology, or who cannot afford to use online services. A great example where the government and industry have taken a joint approach to this is in the waiving of mobile data charges for accessing MSD’s MyMSD service from a smartphone.
Building an Open New Zealand Ecosystem
The Health Information Platform provides a great opportunity for NZ Inc as New Zealand expands our economy from agri/horticulture and tourism into hi-tech and digital services. The nHIP ecosystem provides a marketplace for New Zealand organisations to create and offer new healthcare related digital services.
Datacom as the largest technology company in New Zealand has an ability, and obligation, to foster the growth of New Zealand’s technology startups. We see this as an important role that takes shape on three fronts; the creation of a marketplace in which services can be offered, the facilitation of API usage, and the service aggregation of providers.
- Creation of a Marketplace — thanks to Google’s Play Store and Apple’s App Store, there is a high degree of familiarity across consumers and providers of how marketplaces should work. Most software startups, the kind of participants we need to attract to the nHIP ecosystem, are familiar with the use of marketplaces as a channel for their products. By reusing this familiar framework in the nHIP the Ministry can encourage participation and reduce the barriers to entry for innovation.
- Facilitation of API use — success here needs more than a published list of APIs, it needs local and accessible support to help participants make use of the APIs. We believe this is an important role that Datacom can play, the local API coach, for New Zealand startups.
- Service Aggregation — a challenge with an open marketplace that encourages participation from startups is the ability for startups to provide ongoing support of their applications and services. In a consumer app store it may not matter if an application ceases to work or has no support, but in a health context it is important that widely used applications and services have a degree of certainty, quality and support. We see our role here to provide governance, support and aggregation of offerings to provide a consistent experience for consumers and providers.
The key being that the Health Information Platform ecosystem will not be provided by a single entity, but by a collection of providers, ultimately the value of the ecosystem will exceed the sum of all components. Therefore, the governance of this ecosystem to ensure it works cohesively as one is critical.
Moving from Passive Patients to Active Participants
COVID-19 has made the benefits of a digital health platform overwhelmingly clear. People understand and appreciate the need to be able to access their own information and allow their health care providers immediate permissions so they can access the services they need or the prescriptions they require — without having to physically obtain them. Many of these services were already available — the pandemic has fast tracked the uptake of these, demonstrating how they can make people’s lives easier and more streamlined.
Telemedicine and Virtual visits — once perhaps viewed with suspicion or unease — have become acceptable and normal to many — and they have allowed continuous care regardless of whether countries are in lockdown or have eased out of lockdowns to allow in-person visits.
In the news recently was Southern Cross’ launch of their CareHQ app, which enables New Zealanders to immediately see a GP for a tele-health consultation, using their mobile device. A year ago that could have become a white elephant through lack of trust and comfort; today it makes perfect sense and is poised to enable a new level of access to healthcare for New Zealand.
Many other countries already have digital platforms in use — some are government led and others are led by pharmaceutical companies; and/or health research organisations.
In New Zealand, we can learn a lot from the approaches taken from other organisations — but we need to first talk to and listen to New Zealanders — to understand their needs, motivations and current behaviours — to understand what the best approach will be when undertaking the mammoth task of creating a platform they will be comfortable to use as their own.
Trust
The use of virtual meetings in other contexts in people’s lives — work, family gatherings, communities (e.g church services; gym classes) has helped to demonstrate how this approach to meeting with others is possible. Workplaces have moved to use less paper and store files on the cloud; video meetings and chat functions that promote their encryption features have also helped to bolster uptake. Alongside this increased uptake there have been questions raised around encryption and privacy.
Data privacy is a key implication that needs to be addressed and clearly communicated. Learnings from other industries and categories will be helpful to understanding how we can build trust in the platform to ensure successful uptake — for example finance and e-commerce.
“Beyond the technological problems to be solved, lies the behavioural challenges we will need to identify and address, by designing them into the solution to ensure New Zealanders embrace and adopt the nHIP”
Greg Whitham, Head of CX NZ — Datacom
People may be motivated by understanding the benefits and value they can gain themselves and for wider society.
Motivation
People are demonstrating a willingness to share their data — both PII as well as at an aggregate level where the purpose of sharing their data is clear and beneficial to society or specific groups.
We need to ensure the digital platform and any physical permutations of it are integrated and work together to meet people’s needs. Clarity in the pros and cons (drawbacks/short comings) of each channel are also key to gaining trust and buy-in.
There is a need to make sure the platform creation encapsulates all New Zealanders’ perspectives as input for its creation — able bodied; those at risk; those with accessibility needs — each and every New Zealander.
Value Perceptions
Key to gaining visibility, understanding, trust and ultimately uptake of the platform will be belief in the benefits people will gain from using it. These may include functional/rational benefits such as saving time, ease of access, speed of (info or prescription) delivery, always on — staying connected, helping your family; helping you be healthier — especially as user generated data is included; and learnings we may garner from integrated data sources such as social, location-based info or other demographic info.
Emotional benefits such as making people feel in control of their health (empowered), safe, responsible, motivated, self-assured, informed may also be positive outcomes. Understanding, belief, and advocacy of these benefits may help New Zealanders to adopt and utilise this platform to meet their needs. The platform can also be designed to evolve as needs evolve — ensuring it remains relevant to people’s changing lives and wider societal needs.
