Delivering telehealth solutions to regional New Zealand was no easy task in the first decade of this century.
Mobile Health, which operates a mobile surgical unit and also provides virtual training to rural health professionals, at first used Kordia’s digital microwave radio service to broadcast to 12 locations around the country. The equipment was housed on hospital roofs and cost $1200 per location, per month. The organisation employed a team of four IT staff to maintain the telecommunications networks and infrastructure that delivered ‘standard definition’ broadcast content at 4Mbps.
But since the advent of Ultra-Fast Broadband and the Rural Broadband Initiative, maintaining connectivity is no longer part of Mobile Health’s business model. The hospitals, health clinics, doctors’ surgeries and other organisations it broadcasts to now connect to Mobile Health via fibre, VDSL and, on occasion, satellite and cellular services.
“Now we’re able to focus solely on the content,” says Mobile Health’s CEO, Mark Eager. “We aren’t part of delivering the connectivity, we just tell our clients to get a good internet connection.”
Mobile Health’s marketing manager, Andrew Panckhurst, says the organisation is contracted to deliver 4000 hours a year, and it typically creates content based on the needs of the various health clinics. Along with better connectivity, video-conferencing platforms have also improved greatly and it is rare that a site won’t be able to install a set-up to support a good education session.
Panckhurst says that the use of telehealth solutions varies between District Health Boards. While the technology has improved immensely, Eager says what is lagging in many DHBs are the systems and processes.
“Telehealth is starting to remove some of the barriers for healthcare delivery, so there is less of a rural/urban divide,” says Eager. “But there is not enough happening to change the system, and some of the barriers that are put in place are regulatory. It needs to be led from the top.”
So, is the New Zealand health sector falling behind when it comes to adopting new technology? Ernie Newman certainly thinks so. He was the chief executive of TUANZ (Telecommunications Users Association of New Zealand) when the organisation lobbied for local loop unbundling (this allows multiple operators to use a telephone exchange’s connections). He then went on to lobby for nationwide fibre connectivity.
Newman delivered a scathing assessment of the sector, entitled, Health – A Digital Laggard, at the ITx Conference (New Zealand’s IT conference) in July. And he is preparing for an encore performance at the HiNZ (Health Informatics NZ) conference in November.
In his ITx speech, Newman claimed that the health sector is operating under models devised in the 19th and 20th centuries, and is therefore unable to deliver in the modern digital age.
“The sector’s failing because it continues to put digital band-aids randomly on a system designed for the last century that is totally unfit for purpose in the digital era. There is no shared vision of the destination, nor a master plan to get there,” he says.
“Clinical caution is admirable when they are wielding the scalpel, but ... it can quickly turn to ultra-conservatism, change resistance and patch protection”
Mind Boggling Complexity
“Health service delivery and funding is a system of mind-boggling complexity. A mixture of public and private sectors, with a labyrinth of cross-subsidies, interactions and processes dating back to the time when the medicine man was the wisest and most revered person in the village – nobody would ever think of challenging him. Doctors today still hold that status in society – rightly so when it comes to the practice of medicine, but perhaps wrongly so when it comes to fronting the evolution of the customer interface, structure and funding of a 21st century health system. Clinical caution is admirable when they are wielding the scalpel, but when they are holding the key to the next generation of funding and service delivery it can quickly turn to ultra-conservatism, change resistance and patch protection.”
Since leaving TUANZ in 2013, Newman has worked as a digital consultant with a focus on the health sector. He believes that if change can’t be affected by those working in this sector, then pressure needs to be applied by consumers. This is likely to take the form of lobbying the Minister of Health, David Clark, whom Newman says has a massive job.
He says: “The moment you get into that portfolio you are battered by crisis after crisis. But you need to stand back and take a helicopter view, with a digital bias”.
He says it was “visionary ministers” such as Paul Swain, David Cunliffe and Steven Joyce who successively broke Telecom’s monopoly and enabled the UFB and Rural Broadband Initiative. This at a time when the general public didn’t fully realise how necessary better connectivity is to the development of a small nation like New Zealand.
Newman points to the banking sector as an example that health could follow. He points out that you don’t see a bank manager when you want to withdraw money from your account, so why see a doctor when you have the flu?
“Financial services are a great example – everything starts with the self-service option such as internet banking or ATM machines. Banks in regional areas have disappeared and left prime real estate open for an explosion of two-dollar shops. Aviation and travel have also totally reinvented themselves – airline bookings, check-in, baggage tags and accommodation bookings are fully automated. Education has changed dramatically too. The digital divide aside, most schools now teach digitally. They expect students to bring a digital device to school during the day and use it from home after hours to learn collaboratively or contribute to the class blog,” he told the ITx conference.
“Every one of those sectors and more have achieved those gains by fully embracing the digital era. Crucially, they have re-engineered their customer interface from the start of the digital era, taking the view of a customer looking in rather than a service provider looking out. They have totally transformed the way we bank, travel, learn and interact with government services. The efficiency gains and financial savings have been colossal.”
Newman has written to the Minister of Health and received a perfunctory reply, but he is marshalling resources and is working with TUANZ and HiNZ on creating a “well-informed consumer group to come up with a vision for a 21st century health system and promote it through the political system.”
“Health tends to trail other industries and that's because physicians are dealing with people's lives. It takes longer for the exponential curve (or Moore's law) to come into play”
Health sector catching up
Are Newman’s criticisms of the health sector unfair? Scott Arrol, chief executive of New Zealand Health IT (NZHIT) thinks so. NZHIT is described on its website as “an industry group of health software companies, partners, consultants and healthcare providers, with a broad range of supporting members, including academia, clinicians, researchers and policy makers.”
Arrol says that health may be slower than other sectors, but innovation is starting to occur.
“In any debate or discussion, it’s worthwhile having someone at the extreme edge, that’s how I would describe some of what Ernie says. Some of that is based on historical situations, and not where things are, and where they are heading in the future,” says Arrol.
“Health tends to trail other industries and that’s because physicians are dealing with people’s lives. It takes longer for the exponential curve (or Moore’s law) to come into play.”
In Arrol’s view, the health sector is at the beginning of an exponential curve, and he cites applications such as Melon, Vensa and iMoko (see panel on page 15). These patient or customer-focused solutions are gaining traction. Arrol says part of the issue lies with legislation that is decades old and is in some cases impeding the innovation taking place in the sector.
“The good news is that this is starting to be addressed by the sector, with the Ministry of Health playing an important leadership role,” he says.
In a statement to The Download, the Ministry of Health group manager for digital strategy and investment, Darren Douglass, said that health services are already being delivered to people in their own homes, or on their phone, via a video-link with their doctor.
“Patient portals and other applications provide people with access to their own health records and help them complete routine tasks such as booking appointments or requesting repeat prescriptions. And connected devices allow remote monitoring of patients. Websites provide access to useful information and the ability to connect and collaborate online with their chosen community,” says Douglass.
He says that while healthcare is becoming a more inclusive culture, there is a concern that those without access to reliable connectivity – for either economic or geographic reasons – will miss out.
“Broadband supports this transformation, but we know that those who do not, or cannot access the internet and use digital services, are often those with high health needs. The digital divide is real and we need to close connectivity gaps in rural and remote areas, and address cost barriers for those who cannot afford to access the internet, to ensure that all New Zealanders benefit from access to health information and digital services.”
Meanwhile, Arrol agrees with Newman that the structure of New Zealand’s health sector, with its 20 DHBs, is complex. “I haven’t spoken to anyone who disagrees with that,” he says.
But what are the alternatives, asks Arrol. “If you remove the DHBs in favour of four regions, that could result in an organisation covering an area from the Bombay Hills to Cape Reinga, so how would you cater to the needs of urban Auckland alongside rural Northland?”
Arrol notes that some DHBs have come together to provide co-ordinated solutions. For example, HealthOne (Shared Care Record View) is a secure record that stores patient information. The initiative involves all five South Island DHBs and stores a lot of health information, including GP records, prescribed medications and test results.
Part of the issue with the DHBs lies in their governance structure, Arrol believes. While there are ministerial appointments, the bulk of their governing committees are made up of elected representatives who have a mix of community and business experience. In other words, Arrol questions if many of these well-meaning people who sit on DHB boards have the skills and capability required to govern complex, multi-million dollar organisations.
Reforming the DHB system is an “idea that has to be parked at the moment” says Arrol, at least while the Health and Disability Review is underway. According to the terms of reference on the Ministry of Health website, the review’s purpose is to “identify opportunities to improve the performance, structure and sustainability of the system, with a goal of achieving equity of outcomes and contributing to wellness for all, particularly Māori and Pacific peoples.”
There are two out of 10 areas of consideration that specifically mention digital technologies, and they involve the role of data, as well as the potential of current and emerging technologies to help.
The wide-ranging review is being chaired by Heather Simpson, whose previous roles include Chief of Staff when Helen Clark was Prime Minister. The review committee is expected to deliver its interim report in August 2019 and its final report in March 2020.
While the health sector is taking some steps towards digitisation, the potential for transformation is huge, says Arrol. Blockchain technology, for example, would allow patients to have complete control over their own health record, allowing them to see it and to authorise who can view it.
Going a step further, Arrol thinks initial patient consultations could be carried out by responsive “digital humans”, the kind of emotionally responsive artificial humans being created by Soul Machines. And artificial intelligence, also called machine learning, could be used to analyse the huge swathes of healthcare data generated to produce much more effective diagnostic tools.
“But it all comes back to people, hence the frustration that stuff moves too slow, and I’m one of those people who is frustrated,” says Arrol.
“It all takes longer than it should take. I’m a strong advocate for change, except that you have to try to understand the unintended consequences when you are dealing with people’s lives.”
Sarah Putt has previously been employed by both TUANZ and Orion Health.