A squandered digital decade in healthcare?

It is almost 10 years since the 2013 e-health strategy was launched. Kieran Feely examines the difficulties in implementing the strategy as the Department of Health prepares to publish its new digital framework

Work is currently being undertaken by the Department of Health to finalise the Digital Healthcare Strategic Framework (2023-2030). The framework is intended to provide a direction for digital healthcare to 2030 and will update the existing e-health strategy. The 10-year anniversary of the publication of the current strategy will take place in December.

In terms of marking the occasion, 2023 did not begin auspiciously. In January, Mr Martin Curley resigned from his position as Director of Digital Transformation and Open Innovation at the HSE. That month, there was also the revelation at the joint Oireachtas committee on health that a business case for the implementation of e-health was rejected by the Department of Public Expenditure and Reform (DPER).

Mr Curley’s resignation prompted the committee meeting on e-health on 25 January. In his opening statement, Mr Fran Thompson, HSE Chief Information Officer (CIO), said that in 2018 the HSE sought approval for the procurement of a national electronic health record (EHR). However, Mr Thompson told the committee that approval was deferred until a review of the outcome of the implementation of an EHR in the New Children’s Hospital was completed.

In response to a question from committee member Deputy Neasa Hourigan, the Green Party’s health spokesperson, Mr Thompson said that the business case for the EHR project had been rejected in 2018.

“The Department of Public Expenditure and Reform said it wanted to see the outcomes and benefits from the investments we made in the national children’s hospital prior to making national investments,” said Mr Thompson.

Mr Michael Redmond, Chief Operating Officer, eHealth Ireland, HSE, added: “We do not have a plan to deliver the master plan for the electronic health record because we do not have approval for that.”

E-health strategy

In 2011, a new Government came into office with a reform programme for healthcare. A document titled Future Health was published in 2012 as part of the reform agenda. This document proposed the appointment of a CIO to oversee the implementation of a new e-health strategy.

The eHealth Strategy for Ireland was published in December 2013. The strategy was to be implemented in two phases over a seven-year period. A new independent statutory agency, to be known as eHealth Ireland, was to be set up with overall responsibility for governance around e-health implementation, including funding, legal enabling, public awareness, stakeholder engagement, and building the e-health ecosystem. The strategy document admitted there was a lack of public confidence in the ability of the HSE and Government departments to deliver major ICT initiatives.

An eHealth Ireland board was to be appointed and an eHealth Ireland forum set up with representatives from Government departments, academia, industry, the voluntary sector, and patient groups.

eHealth Ireland was never established as an independent agency along the lines outlined in the document, with a board and forum. Instead, a new unit was set up within the HSE, which carried the name. Mr Richard Corbridge was appointed CIO in 2014 and an eHealth Ireland committee appointed in 2015.

A ‘knowledge and innovation’ strategy was published by eHealth Ireland in May 2015. The strategy envisaged a five-year delivery timeframe and set out the key capability and operational requirements.

Business case

This strategy was followed in May 2016 by a business case for the implementation of the e-health agenda. The business case stated that the national EHR would have four components: The national shared record delivered by a portal; community operational systems; acute operational systems; and an integration platform to securely share all the systems and integrate across all care settings.

Based on a review of scientific research, the business case contained examples of specific benefits of implementing EHRs, including a 25 per cent reduction in emergency attendances, a 37 per cent reduction in preventable hospitalisations and a 35 per cent reduction in medication errors.

“As organisations move to the healthcare system of tomorrow, it will not be possible to achieve the aims of improving patient outcomes, enhancing the quality and safety of patient care, and reducing costs without maximising the use of technologies including EHR”, the business case stated.

The estimated cost of the approach set out in the business case for the nine-year implementation plan ranged from €609 million to €824 million.

Correspondence between DPER and the Department of Health relating to the approval of the business case for the EHR was released to the Medical Independent (MI) under Freedom of Information law. A letter from DPER to the Department of Health, dated 24 January 2019, stated that there needed to be a review of the capacity for the project to be funded within the constraints of National Development Plan ceilings, given the current pressure on the health capital allocation following the substantial overruns at the New Children’s Hospital.

The author of the letter, Mr David Moloney, then Assistant Secretary (current Secretary General), said that he wanted to clarify DPER’s position on the EHR project.

“We had understood that the model was to be applied, in the first instance, at the [New] Children’s Hospital,” according to the letter.

“At no stage has any approval or sanction been provided for the roll-out of either a children’s hospital EHR or a national EHR. We have concerns that in seeking Government approval to roll-out a national project there would be subsequent delays for the roll-out of phase 1 at the children’s hospital. It would, therefore, be most appropriate to seek Government approval to implement an EHR at the New Children’s Hospital first.”

In his reply, dated 12 February 2019, Mr Muiris O’Connor, Assistant Secretary at the Department of Health, wrote that efforts to secure funding were successful and that there seemed to be a misunderstanding on the part of DPER as to the scale and scope of what was proposed. Mr O’Connor noted that “we keep getting pushed back to the starting line”.

MI asked the Department of Health how much of the €10.9 billion allocated to the Department of Health under the National Development Plan 2018-2027 was allocated to the e-health programme referred to in O’Connor’s letter. A spokesperson provided figures for global ICT capital allocations, but the specific information requested in respect of e-health was not provided. Separately, the European Investment Bank (EIB) announced in October 2018 that it had agreed to provide a loan of €225 million to support the roll-out of Ireland’s e-health programme. The EIB confirmed to MI that the loan has been drawn down.

This newspaper also asked the Department for details of the loan, including what projects the loan had been spent on and the amount expended on each project. A spokesperson said the loan was drawn down on 8 October 2021. This is 33 months after the e-health business case was rejected by DPER.

The spokesperson for the Minister said that the loan was “focused on strategic ICT investment areas, such as foundational infrastructure, cyber resilience, the integrated financial management system, and the delivery of various forms of electronic health records”. The information requested in respect of individual projects was not provided.

The HSE position

Three years after the business case was rejected by DPER, the board of the HSE was asked for guidance and strategic direction in relation to e-health. A briefing document presented to the board by Mr Thompson at its meeting on 27 May 2022 stated that the EHR programme was “effectively paused” after the HSE received direction from DPER that there should not be any further deployment of the EHR until after the New Children’s Hospital programme has been implemented.

The briefing document stated that the required e-health transformation could not wait and that a de-facto plan B was being pursued, which sees tactical solutions deployed in specific care settings. Mr Thompson told the meeting this was a sub-optimal way of delivering e-health and significantly increases complexity within the ICT landscape. The current approach was likely to take many years to implement at current levels of investment and would see only sporadic breakthroughs in e-health capability.

Mr Thompson asked the board to consider two options for e-health. The first option, plan A, was to adopt a strategy of implementing a national EHR programme. The second option, plan B, was to continue to implement tactical solutions. The minutes of the meeting record the board as supporting implementation of a national EHR programme. Despite this decision, the HSE continues to deploy tactical solutions.

Implementation and cost

The HSE told MI that deployment of an EHR nationally will take between five and seven years once the sanction and procurement is complete. Separately, the minutes of the HSE board meeting on 2 September 2022 record that the implementation of an EHR system will have a core deployment phase of seven-to-10 years and a total implementation timeframe of 20 years. The minutes state that the CIO advised the board that the 20-year timeframe was in line with the recommendations of DPER.

The estimated cost in the rejected business case for a nine-year deployment was between €609 million and €824 million. According to minutes of the meeting on 2 September 2022, the HSE board was told that the estimated cost of the EHR deployment was €1.4 billion. The board was also told that a further €656 million was required for the ICT and cyber programme over a period of seven years. “In summary, the estimated funding allocation required by the HSE could be up to €2.1 billion to achieve a successful and secure e-health transformation,” said the minutes.

MI asked the HSE to explain the differences in timelines and estimated costs. A spokesperson for the Executive responded that the timelines had different scope and deliverables. The spokesperson said that deploying an EHR nationally will take between five and seven years once the procurement and sanction is complete.

In relation to estimated costs, the spokesperson said that the 2016 business case was based on pre-procurement market soundings. The scope of the programme covered all acute hospitals and community services.

The projection provided to the board in September 2022 was a very high-level estimate based on international estimates adjusted for Ireland and included the costs of the cyber remediation programme. This estimate assumed a core deployment of between seven and 10 years and that additional modules would continue to be deployed for a significant period following that.

Living labs

Following Mr Corbridge’s resignation, Mr Curley was appointed as CIO in 2018. However, in 2019, he took the new role of Director of Digital Transformation and Open Innovation and Mr Thompson became CIO in an interim capacity. Mr Thompson is currently CIO on a permanent basis. The HSE told MI it intends to fill Mr Curley’s position as Director.

In reply to another press query, the HSE confirmed that the last meeting of the eHealth Ireland committee took place in September 2019 and that the committee was no longer in place. It has been replaced by a new HSE technology and transformation committee, which was formed last year.

In an interview with MI, Mr Curley said that the 2013 strategy was quite visionary. However, he pointed out that the manner in which the HSE was attempting to procure the EHR, with many specifications in lengthy documents, lacked flexibility.

“The approach I’ve been using is a ‘living lab’ where you work to develop a prototype,” he said.

Living labs are described as user-centred, open innovation ecosystems/environments. They are intended to integrate concurrent research and innovation processes, within a public-private partnership context. In 2020, the launch of the network of digital health living labs was announced by the HSE.

Mr Curley cited the development of the epilepsy electronic patient as an example of this approach.

“The ‘living labs’ methodology is a way of introducing disruptive technology in a non-threatening way, where you manage the risk and use agile methodology,” according to Mr Curley.

Mr Curley gave as another example the implementation of a ‘digital vital signs’ solution in Cavan General Hospital. He said that the solution remotely identifies a deteriorating patient quickly and automatically computes the early warning score.

Mr Curley maintained that the HSE had a leadership position in 2013 with the e-health strategy, but argued progress has been too slow.

“We have moved just incrementally and it’s just not acceptable for the Irish people. Sub-optimal decisions are being taken and sometimes these are catastrophic for people,” said Mr Curley.

“We have doctors and nurses making decisions with Victorian tools,” said Mr Curley. “Data saves lives, the lack of data takes lives,” he said.

He said healthcare systems have made remarkable progress over the past number of decades, but that the healthcare model is breaking down due to ageing populations, lack of capacity, and staff attrition. There is what Mr Curley describes as a “model crisis”.

He believes there must be a move from illness to wellness.

“The big returns are on keeping people well and we now have the tools and technology where we can detect chronic disease early and help reverse it. Small shifts into wellness will have dramatic returns,” he said.

The second requirement, according to Mr Curley, is to create an informed patient where there is a personal electronic health record on a personal communication device that provides the point of integration for the patient and the healthcare professional.

Thirdly, Mr Curley maintained that there must be a move from hospital to home.

“We now have technology for getting vital signs at home that is better than the technology available in hospitals,” he said.

E-health and Sláintecare

The Sláintecare Report (2017) stated that the speedy implementation of the e-health strategy was central to the successful delivery of integrated care. The report made several recommendations in relation to e-health. These included: Continued strong support of the e-health strategy; the development of a hospital waiting list management system; streamlining the approval-to-spend process for the e-health strategy between the Department of Health and the Office of the Chief Information Officer in the HSE; and the development guidelines addressing parental access to the electronic health records of their children.

The importance of e-health to implementation of Sláintecare was acknowledged by the then Minister for Health Simon Harris in 2017. Speaking in the Dáil about the strategy, Minister Harris said: “I will pick e-health as an example. We simply cannot achieve the responsive, integrated, effective system that we all desire without significant investment in information systems.”

This view was echoed by Ms Rachel Flynn, Director of Health Information and Standards, HIQA, at the launch of the Authority’s report, The Need to Reform Ireland’s National Health Information System in 2021.

“The success of Sláintecare requires urgent reform of health information and this will require reform being made a political priority. Today’s report is calling for urgent reform and should serve as a wake-up call for all stakeholders in health and social care to make health information a high priority,” said Ms Flynn.

The Sláintecare Action Plan 2022, published by the Department, stated the intention to publish a refreshed e-health strategy in the fourth quarter of 2022. However, this did not occur. The recent progress report for the year revealed there had been a “minor delay” with the plan.

“An outline draft strategy has been prepared by year end,” according to the progress report.

“Quarter 1 2023 will be used to consult and engage with stakeholders before finalising same.”

A spokesperson for the Department said the development of a Digital Healthcare Strategic Framework, as a successor to 2013 e-health strategy, is almost complete. The Sláintecare Action Plan 2023 stated the framework would be published in April.

The framework will complement the Health Information Bill, which is also being developed (see panel). According to the spokesperson, the Department and the HSE decided to take a joint approach with the new strategy. The Department has taken the lead in developing the framework document. It will reflect the Government digital strategy Harnessing Digital, Department policy, EU obligations, as well as other international developments.

The spokesperson said the HSE is developing a digital health strategic implementation plan to be published later this year. The framework and associated implementation plan will provide a roadmap for how EHR systems will be approved, procured, and deployed in the future. It will also set out how interoperability standards will enable the provision of national EHRs, shared care records, summary care records, and the ability for patients to access their own health data, digitally, in the future. It will help to accelerate the programme of work required to deliver electronic health records for the entire population, said the spokesperson.

The Sláintecare action plan for this year contains the commitments to “mobilise the shared care record programme as an essential enabler to delivering summary and shared care electronic health records for all”. It also commits to developing a “roadmap and investment case for EHR deployment”