Enterprise Case Study: Using IT to Improve Ireland’s Public-Sector Healthcare
This case study revolves around how how eHealth Ireland is learning from professionals, patients and England in building national healthcare IT. eHealth Ireland has taken an incremental approach to digitizing healthcare in the Republic of Ireland, having focused on infrastructure, clinical involvement and implementing software in maternity units before starting procurement of the country’s National Electronic Health Record in 2017. Such groundwork increases the likelihood of this project’s success and helps vendors to understand Ireland’s needs and choices. Ovum’s analyses of this is that eHealth Ireland has correctly recognized that the introduction of new software used across a healthcare organization or system is a business change project first and a technology project second. Chief executive Richard Corbridge has learnt from the mistakes of England’s National Programme for IT by establishing high levels of clinical and patient involvement.
Using IT to improve Ireland’s public-sector healthcare
In most developed countries healthcare was developed through a transactional model of episodic delivery by single organizations such as hospitals and primary-care doctors. Patients generally returned to those organizations, and they held the records of care. The delivery of healthcare has changed, with patients increasingly treated for chronic conditions by multiple healthcare providers over their lifetimes, requiring records to be available across organizational boundaries. This is particularly true within all-purpose healthcare services, such as national and state systems and large private groups. Healthcare IT has a poor record on integrating provider organizations, including public-sector groups. Unavailability of records is costly for providers, as it wastes professionals’ time, generates unnecessary repeated tests and is inconvenient and in some cases dangerous for patients. The development of integrated electronic health record systems within groups, regions and nations is among the most important tasks for healthcare providers.
Irish public-sector healthcare
The majority of healthcare in Ireland is provided by the government, which was responsible for 66% of the country’s total expenditure on health in 2014, compared with 83% in the UK and 48% in the US. [World Health Organization data] As in the UK, Ireland’s public healthcare system is open to all residents, but with its citizens making greater use of the private sector. At 7.8% Ireland spends a relatively low proportion of gross domestic product on healthcare overall (UK 9.1%, US 17.1%) and the country’s public sector has undergone severe cut-backs following the financial crises of the late 2000s. Its public healthcare system has made significantly less use of IT than those of other developed countries, despite the country’s well-developed IT industry.
Learning how not to do it from England
eHealth Ireland’s chief executive Richard Corbridge joined the organization in December 2014 from National Institute for Health Research, part of the English National Health Service (NHS). Corbridge had previously worked on the NHS National Programme for IT (NPfIT), a project which had attempted to impose electronic health record software on the NHS trusts which run hospitals and provide secondary healthcare in England. Launched in 2002 by then prime minister Tony Blair, NPfIT intended to impose its choices across the English NHS, with software chosen nationally and installed by centrally-chosen contractors. The views of NHS trusts and healthcare professionals were largely ignored, and they became increasingly hostile to the scheme. One of the main suppliers Accenture pulled out and by 2007, when 155 hospitals were meant to have administrative software live, only 16 did. [King and Crewe pp196-199]
In September 2011 the coalition government announced the scrapping of NPfIT. Although it successfully established some national IT infrastructure and specialist systems in areas including imaging, NPfIT has become notorious as an example of how not to carry out a national healthcare IT project. Ireland is, effectively, using NPfIT as a guide of how not to digitize a nation’s healthcare IT. For example, Corbridge mentions its failure to engage with medical professionals as his reason for establishing a national clinical chief information officer (CCIO) council soon after taking the job; it now has 210 members from both public and private healthcare organizations. Last year, eHealth Ireland established a ‘quality knowledge corridor’ project through which clinicians can propose problems that IT could help solve; so far 45 have been accepted for further work, including a mental health organization’s request for an app that will support meditation by playing audio files of instruction and recording when a patient uses them.
Similarly, Corbridge has aimed to answer the privacy issues that arise from joining up healthcare records by assuming patients are not in favor of their records being shared with researchers unless they say so, an issue that generated many complaints against the NHS, where sharing by healthcare professionals is enabled by default and patients must chose to turn it off.
A determination to learn from NPfIT’s failings is also evident in eHealth Ireland’s approach to local work. The plan to implement maternity record software (see below) predates eHealth Ireland, but was allowed to continue as it would deliver benefits to a type of hospital with particularly poor technology. (NPfIT involved the cancellation of IT projects that predated it.)
More generally, each of Ireland’s seven healthcare groups (government-owned providers running multiple sites, comparable to a large English NHS trust) will retain its own IT management and capacity; each now has an eHealth director who is professionally responsible to Corbridge but who reports to the chief executive of their own group. NPfIT’s greatest problems arose from conflicts with NHS trusts, the local provider organizations that actually deliver most healthcare; the appointment of specific link people at the healthcare groups should reduce the risks of similar problems at eHealth Ireland.
There were 3 key messages in the solution. They were:
Recommendation for Enterprises
One of the first things Richard Corbridge did after taking on the role as head of eHealth was to established a national chief clinical information officer council. The organization is running extensive public sessions to involve patients in the design of its National Electronic Health Record. The recent relatively pain free implementation of maternity software at Cork University Maternity Hospital has demonstrated both the value of strong clinical input, but also the need for support and training for staff involved.
Recommendation for Vendors
In moving the Republic of Ireland towards digital healthcare, eHealth Ireland has started with basic infrastructure, including a shared secure email system and a patient identifier numbering system. It has adapted a pre-existing plan for electronic health records in maternity wards into a pilot for its National Electronic Health Record project. The first site to go live with that maternity software has demonstrated the need for significant spending on user devices, networks and peripherals. Adopting an incremental approach minimizes risks, both for the customer and for vendors, who risk being blamed for failed implementations of their software caused in part or whole by inadequate infrastructure.
Irish public-sector healthcare
To tackle this, Ireland’s Department of Health announced the setting up of eHealth Ireland as dedicated agency to deliver and coordinate IT systems for the country’s public healthcare providers in its June 2013 eHealth strategy. eHealth Ireland is charged with implementing such systems “as a national infrastructure investment and [ensuring] that the benefits to the Irish people and the state are maximized,” recognizing that Ireland and other countries have suffered from a fragmented approach. The strategy also charged the new organization with encouraging local and regional initiatives, rather than trying to dictate policy from the center and ignore or cancel existing work. [Department of Health 2013, p53]
Aside from learning from England’s mistakes, eHealth Ireland has put a lot of work into establishing and adjusting Ireland’s healthcare IT infrastructure before going ahead with big projects. The most important element of this is the Individual Health Identifier patient numbering system, which was detailed in the June 2013 strategy document and required legislation, the Health Identifiers Act 2014. The IHI National Register was established in December 2015 with data covering 4.78 million people, and its use is a legal requirement for both public and private sector healthcare providers. The data included within IHI, which is defined in the act, is fairly minimal and does not include any health data. Arguably this is an area where Ireland has learnt from the UK, given the existence of the NHS Number system in England and Wales since the 1940s and similar systems in Scotland and Northern Ireland.[http://www.ehealthireland.ie/Strategic-Programmes/IHI/ Ovum report on health identifiers] eHealth Ireland has established and adapted other pieces of infrastructure. In September 2014 it launched a national email system Healthmail which now covers more than 1,000 general practitioners and support staff and 30 agencies, along the lines of NPfIT’s successful NHSmail project. [http://www.ehealthireland.ie/Case-Studies- /Healthmail/] It now manages Healthlink, a web-based messaging service for clinical patient information that has been in operation since 1995. [http://www.ehealthireland.ie/Healthlink/] Corbridge has changed the role of regional IT offices which used to do everything for a region, so that each now has a specialist role: the office in Cork focuses mainly on technology, Kells handles project management, Galway service management and Dublin acts as the head office and design authority.
Giving birth to the national EHR: Cork University Maternity Hospital
Planning for the Maternal and Newborn Clinical Management System (MN-CMS) started well before the formation of eHealth Ireland, with a project board set up in 2007 and public procurement starting in 2011. However, it has been implemented under eHealth Ireland, which means it is acting as a pathfinder for the larger EHR project. Richard Corbridge says that it made sense for the MN-CMS deal to progress, given that the country’s maternity hospitals had particularly poor IT, but also given his belief in ‘best of breed’ procurement with specific systems for different specialties.
MN-CMS’ project team, which is now part of eHealth Ireland, awarded the deal to Cerner as the supplier in February 2014; in September 2015, Cerner also won the National Medical Laboratory Information System (MedLIS) deal. [http://www.ehealthireland.ie/Strategic-Programmes/MNCMS/] Cork University Maternity Hospital went live with MN-CMS on 3 December 2016, the first of 19 hospitals to deploy the system over two and a half years; Kerry General Hospital’s maternity wards in Tralee will be next.
Although it was largely successful, lessons have been learnt from Cork’s go-live. One is that Cork University Maternity Hospital lacked IT infrastructure such as wireless networks, laptops and printers; before the go-live, it relied on paper records. Another is that extensive staff training was needed. Corbridge says that staff underwent a total of 9,800 hours of training, with ‘super-users’ getting two weeks and other staff four or five days. He says that eHealth Ireland has learnt that sites will need to be supported heavily at go-live, with what he describes as “plenty of input and TLC”.
The implementation involved making other significant choices, which may act as precedents for the national EHR. Although most births take place over hours or a few days, Cork’s Neonatal Intensive Care Unit can look after newborn babies for several weeks. Rather than having ‘paper babies’ and ‘digital babies’ co-existing, the team decided to move all patients from paper to digital records on 3 December as otherwise the unit would have to run both systems in tandem for a period of time.
At go-live the unit experienced technical problems in linking Cerner’s FetaLink fetal monitoring to core systems, although these were solved within a few days. Corbridge says that not all the systems in the unit went live on day one and this shows the need to have the ability to roll-back new systems temporarily during a go-live.
The implementation showed the importance of senior clinical involvement with the project. Cerner’s Ireland general manager Michael Pickett says Cork was a fortunate choice as the first site, as two of its clinicians were heavily involved with the national design of MN-CMS, which contributed to confidence among their colleagues at the maternity hospital. He says that the project started with low levels of local IT knowledge given the hospital relied on paper, and that local leadership has been vital in encouraging staff to use the system. Corbridge adds that the Cork go-live also showed it is important to reassure clinical staff that their jobs were not fundamentally changing, as some were worried about the introduction of IT.
eHealth Ireland publicized the birth of baby Emily to Ellen Shine and Aidan Cotter at Cork University Maternity Hospital on 3 December, with the Irish Times calling her “Ireland’s first digital baby”. The fact that Emily and her peers have digital health records from birth was used by eHealth Ireland to promote its broader work, with health minister Simon Harris describing the Cork go-live as “a very significant advance in our national journey towards a digital health system”. [http://www.irishtimes.com/news/health/meet-emily- ireland-s- first-digital- baby-1.2893670, http://www.ehealthireland.ie/News-Media/News- Archive/2016/First-babies- born-with- an-electronic-health-record.html]
Learn from the mistakes and successes of others
eHealth Ireland has gone to great lengths to learn from the mistakes and successes of the English NHS, in particular its National Programme for IT, to the extent of hiring an English chief executive who worked on the project and has based some of his decisions on this experience.
Learning from UK experience is a good strategy for the Irish public sector; its larger neighbor has greater resources and tends to move earlier on technology projects, although not always wisely. Given its proximity, ease of travel and a shared language it is also easy for Ireland to import expertise from Britain. Increasingly, as Ireland develops its public sector IT capabilities, counterparts in the UK should seek to learn from Irish experiences. More generally, those planning significant IT projects will always benefit from considering forerunners.
It should be said that designing a project purely by reversing approaches taken by a similar, flawed one can risk fighting the last war rather than the present one. However, eHealth Ireland has also adopted successful NHS practices including a national patient identifier and secure email system, and is forging its own course in patient consultation.
Involve professionals and patients (or customers) in planning
Any healthcare IT function should consult senior healthcare professionals if it hopes to have its systems used effectively, and the appointment of chief clinical information officers has become a standard part of how to achieve this. eHealth Ireland’s early decision to form a council of CCIOs should contribute significantly to the success of its national work. Similarly, the recent implementation at senior Cork University Maternity Hospital benefitted from the involvement of two of its senior staff in the national MN-CMS project.
The early involvement of healthcare professionals in IT projects has become common practice, but fewer involve patients in their planning. Although it is too early to assess its impact, eHealth Ireland’s public consultations over the 20 personas designed to represent the Irish population is a welcome attempt to include patients in the design of the national EHR system at an early stage. While IT projects in other industries often carry out extensive user testing at later stages, the idea of involving professional and public end-users in the planning stage is one that could be usefully adopted elsewhere.
The National Electronic Health Record
Having implemented building blocks such as the Individual Health Identifier, secure email and having introduced new software at its first maternity unit, eHealth Ireland is about to start procurement of its biggest project. This is a national Electronic Health Record (EHR) with a likely budget of EUR850m, announced in April 2016. The project is the cornerstone of Ireland’s eHealth strategy, aiming to significantly transform the country’s use of technology and data in providing care. [http://www.ehealthireland.ie/Strategic-Programmes/Electronic- Health-Record- EHR-/]
eHealth Ireland hopes to publish its business case for the project by St Patrick’s Day (17 March) 2017, including a decision on whether the implementation will take place over five or nine years. However, the organization has already discussed the project’s basic structure, which will be split into four lots:
- Acute HER
- Community HER
- Integration work
- Patient and staff portals
Each lot is likely to be awarded to a single supplier, except for the portal work which may involve separate companies for the patient portal and the one to be used by healthcare staff. eHealth Ireland has developed its plans in association with suppliers, holding an event in 2014 that involved more than 150 companies as well as detailed discussions with vendors and system integrators. [http://www.ehealthireland.ie/Strategic-Programmes/Electronic- Health-Record- EHR-/Progress/]
However, it is also carrying out extensive public engagement with Irish citizens as part of the design of the project. On 31 January and 1 February 2017 it held four workshops in Dublin to help in the development of 20 representative personas of the Irish population, which suppliers will be expected to show they can serve. Due to demand, it increased the number of places per session from 100 to 150. [http://www.ehealthireland.ie/Strategic-Programmes/Electronic- Health-Record- EHR-/Personas-Workshop/]
One of the Dublin workshops was focused on pediatrics, reflecting the importance of children’s health within the EHR project. Ireland is developing a new National Children’s Hospital, its single largest healthcare infrastructure project, which will combine the Dublin area’s Children’s University Hospital, Our Lady’s Children’s Hospital and the National Children’s Hospital. The new hospital will be ‘born digital’, with less physical space for administration and high levels of automation, tracking and monitoring. As it will continue to the use the three sites of its three predecessor hospitals in a ‘hub and spoke’ model, with the hub at what is currently the Children’s University Hospital on Temple Street in central Dublin, technology will also be required to share patient information between the sites. [http://www.ehealthireland.ie/Strategic-Programmes/National- Childrens-Hospital- NCH-/]