An imminent report from the Health Boards Executive (HeBE) will be the most comprehensive document yet to champion the part that technology can play in overhauling the beleaguered health service. The strategy paper is expected to provide a detailed framework and action plan for the creation of a world-class healthcare system by 2010. Short-term goals are dependent on the Department of Health making a substantial increase in its budget for ICT (information and communications technology) and new legislation that will pave the way for the introduction of a unique patient identifier.
Investment in ICT currently represents approximately 1pc of the Department of Health’s budget, a figure that HeBE’s director Dennis Doherty would like to see increased to 5-6pc “in the shorter rather than the longer term”. Alternative strategies in the new report will point to funding and support through public private partnerships and outsourcing.
The money available from the department has already doubled from €30m in 2003 to €60m in 2004, but there is still a common view that ICT adoption and deployment is grossly under-funded, something that must be addressed as a matter of urgency, according to Doherty. “There will be many definitions of ‘world-class health services of the future’ but what we’re saying is that any such service has to be ICT enabled,” he states.
Clear benefits that disparate technologies can bring to Ireland’s health service include PPARS (personnel payroll and related systems) solutions for all of its 80,000 employees, medication and order management tools for its administrators and clinical intelligence and decision support systems for its front line staff.
Any budgetary increase must be sanctioned by the Department of Health, Finance and the new Health Service Executive; something that is unlikely to happen until other elements of the reform process are put in place. Following on from last year’s publication of the Prospectus, Brennan and Hanly reports, the Government has faced ongoing criticism for delays in implementing the proposed reforms. When the changes do start to happen, HeBE is hoping that its framework will enable a better understanding of how ICT can underpin the new healthcare system and help secure a bigger slice of the budget.
“This message hasn’t got across in the past,” says Doherty. “There’s a mantra going back many years in the health service that when times are tough we ought to be protecting the front line staff. But all staff are important. When a boiler doesn’t kick in, in an old people’s home for example, the boiler man also becomes a key employee. It’s about how we can support the staff in all areas, on all levels, through investment in enabling their work through ICT.”
According to Doherty, there is still a perception in the public sector that technology is an optional overhead, confined to computers and software rather than processes that can enable significant change, increasing efficiencies and ultimately saving money. “When we talk of a 6pc budget we are talking about money for hardware, software and the change processes associated with them. The change processes would cost significantly more than the other components,” he explains.
The premise of the ICT strategy report is that funding of technology is fundamental for healthcare and its most basic responsibilities. “We’re not talking about investing in systems to have state-of-the art technology; we’re talking about investing money to save lives,” says Tom Carty, a HeBE executive who was instrumental in compiling the document.
“An unsupported system will continue to cause large number of potential difficulties,” he says, referring to reported figures of system errors that in worst case scenarios contribute to a loss of life. “It’s getting more complex and there are many more demands being placed on people and they need help.”
The problem for ICT advocates in the health sector is a legacy of inefficiencies. Back in 2001 the Deloitte & Touche Value For Money audit identified problems caused by having disparate boards and agencies, each acting as its own fiefdom and exercising it own autonomy. There were too many systems in place, a lack of national co-ordination in their deployment and a tendency to repeat implementation processes rather than collaborate and share experience.
Carty says that the new report recognises these failings and makes a strong case for more rigorous ICT investment. “If we are looking for significant improvements in levels of public funding there must be a massive improvement in our accountability,” he admits, “with more particular reference to investment appraisal, ongoing benefits and a whole series of approaches to managed risk.”
New systems and processes will be put in place to ensure that procurement is robust and cost effective, increasing the chances of success in what Carty admits is a notoriously difficult area of project management. “It’s very clear if you look at something such as Gartner research that IT projects fail, and large IT projects fail big. We will put the effort into doing it once and once only and then try to get the solution for the whole enterprise [the national healthcare service] out of that procurement. There will be an investment appraisal, a setting of expectations. Then we put in place the change management,” he adds.
One of the challenges for HeBE has been in outlining a strategy before many of the reforms issues have been resolved. “Growth to 6pc investment depends on how quickly we want to advance the reforms and restructuring,” says Doherty. “We were aware that significant change was coming down the track and approached it on the basis that it would be robust against uncertain futures.”
Part of the jigsaw that the HeBE team wants to see sooner rather than later is legislation that will enable a citizen’s Personal Public Service Number (PPSN) to be used as the basis for a unique patient identifier that would correspond to an electronic patient health record. The idea is that a single ID will help healthcare practitioners access a patient’s history regardless of the location or specific nature of the care.
“We need a unique identifier to match the activity with a person to ensure safety and quality, and not mistakenly refer to someone else,” explains Carty. “The PPSN is a means to that end.”
The problem is that a legislative change is required because the PPSN is defined by the 1998 Social Welfare Act as a unique identifier between citizen and State. This criteria would have to change to enable private practitioners to use the number.
Workshops in the Reach government agency have been exploring identifier services across the entire spectrum of the public sector and construction has now begun on the Public Services Broker where the aim is to enable citizens to access multiple services with a single ID. While Carty welcomes such initiatives he wants to see some real progress in his own sector. “I’d like to get us to a legislative empowered scenario whereby we can use the PPSN as a unique identifier across the entire health system,” he hopes.
At the backend, the plan is for electronic records that will offer different views of the patient, depending on the nature of the healthcare interaction, but derive from a single data set. Collectively such records would create a vast knowledge pool.
“When systems such as order communications and clinical decisions support are firmly rooted in detailed electronic health records, they will start to pay huge dividends because we’ll be able to analyse, mine and get the benefits of past knowledge,” explains Carty.
He is, however, mindful of how much the Department of Health should try to achieve with the introduction of electronic patient records. “If you go for a 100pc solution we’ll be at it for decades. But I think a robust basic record could be in place in a small number of years,” he reckons.
He believes the best way forward is for health service stakeholders to sit down and agree on the remit and the content for a basic record, selecting the data elements that need to be recorded, where they’re stored and how they’re accessed.
“I see a record being built around the greatest needs. Cardio and cancer treatment, for example, would be greatly helped by common data sets,” he says. “It would make it possible for extremely valuable analysis.”
Another missing link, and crucial to the deployment of technologies, is the proposed setting up of a shared services centre that will leverage cost savings by rolling out new systems on a national basis. The precise makeup of this organisation is still to be defined but Carty recognises that it will have to appease existing parties so a centralised one-stop HQ is highly unlikely.
“I’m not so sure the research has been done as to whether it should be nationally, centrally or locally devolved, but it’s highly unlikely that they will set up a single geographic national shared services centre in a green field,” he adds.
While planned reforms include a dramatic reduction in the number of health boards, local ownership and accountability are very much part of the HeBE vision but not at the risk of duplication.
“It wouldn’t make sense in a single health enterprise to have a multiplicity of operational units all doing the same thing unless they have been co-ordinated. It will need significant consolidation,” says Carty. “You would want to end up with a national, regional and local dimension. There are elements that can be centralised but change management and the deployment of support systems will still require people out in the front line.”
Digging down deeper into HeBE’s plans for the rollout of new IT systems, Carty makes it clear that the disparate requirements of the service means that solutions have to be carefully deployed.
“We’re going for single enterprise solutions that have enterprise-wide applicability,” says Carty. By way of explanation he cites the ongoing rollout of SAP enterprise resource planning (ERP) systems and plans to deploy iSoft, a solution for hospital information systems support. After an initial and controlled deployment both will be rolled out into other locations. A phased and controlled approach will hopefully obviate the risk of any large-scale disasters.
“We’re not talking about one size fits all,” says Carty. “But we must try to identify what can be deployed across the enterprise to ensure we get the best value in the shortest possible time frame.”
When it comes to Ireland’s health service, there will be many who say that it’s an objective that’s very welcome and long overdue.
By Ian Campbell