The recent implementation of My Health Record by the Australian Digital Health Agency (ADHA), though well intentioned, has been met with a mixed reception. Whilst there is general in-principle support for a national electronic health record system, it seems that the issue is in its implementation. This article considers the case for change, current challenges and a new change management approach.
The Case for Change
When implemented effectively, health technology innovations can drive us closer towards achieving the Quadruple Aim – improving population health, patient experience, and clinician/care team experience while reducing costs.
I. Enhanced Health Care Delivery
Adopting digital technologies may enhance the delivery of health care and facilitate the clinician-consumer relationship. Information technology enables informational continuity, and provides a clear signal to patients that “someone knows who I am”. According to AMA President, Dr Tony Bartone:
“…access to [patients’] summary of the repository of their information [through My Health Record]; gives them control; and gives them additional engagement in their health journey; and improves health literacy. All of these things will improve their health journey and their health outcomes.”
II. Data-driven Improvement
The improved collection, extraction and analysis of health care data can provide rich insights and allow for data-driven improvement. Integrated data sets provide health systems with opportunities to more carefully observe the patient journey across the health care continuum, and begin to measure and influence patient outcomes.
The Western Sydney General Practice Data Linkage project features in the Bilateral Agreement between the Commonwealth and New South Wales. Accordingly,
“It represents the first time in NSW that data have been extracted from the electronic health records of general practices, transferred to NSW Health and linked to state health system records including emergency department, hospital and mortality records.”
The project aims to understand patient care across the health care system from primary to tertiary care, and inform health system planning.
Internationally, only a few countries utilise data linkage systems. These countries include Canada, England, Denmark, Scotland and the US. The earliest example in Australia was in Western Australia in the 1970s. This led to the creation of the WA Data Linkage Unit in 1995 (Emery J, Boyle D, 2017).
Failed implementation can have deleterious effects on the delivery of health care. If new technologies negatively disrupt the workflow of clinicians, the patient-doctor relationship may be strained. Ideally, technological platforms speed up, and where possible, automate tasks so that more time becomes available for patients and their care teams to interact.
I. Clarity of Purpose
Being clear on the reasons for implementing any health IT system is critical to the change process. In the case of My Health Record, enabling patient control over data, and creating opportunities for data-driven improvement, are powerful reasons to persevere with its implementation. The power of observation and measurement is articulated in the below statement by Dr Wayne Dyer:
“When you change the things you look at, the things you look at begin to change.”
Dr Dyer takes this down to the subatomic level, describing the phenomena in quantum physics by which particles change through the sheer act of observation. In the world of health care, by measuring progress towards objectives, we can begin to consider how what we do in health alters clinical, operational and patient experience metrics.
In the words of Peter Drucker, also known as the man who invented modern business,
“If you can’t measure it, you can’t improve it.”
In health care, the greatest argument for the implementation of robust IT infrastructure is quality improvement. Without measurement, we are confined to doing the same things over and over again, without regard to whether or not we are making a difference to the health of populations and influencing the quadruple aim.
II. Gaining Buy-In
As Michael Porter describes in his video on value-based health care, traditional health care management has relied on strategies that control cost, and in many parts of the world, including Australia, health care funding has not evolved beyond volume-based payments. Increasingly, health care leaders are demanding a shift in focus towards value.
With incomes in primary care determined by fee for service, there is little imperative to measure outcomes, and thus it becomes difficult to drive one of the fundamental arguments to implement strong IT systems – that effective IT systems enable measurement, monitoring and improvement. Questions such as who owns health care data abound, and it is yet to be determined where accountability for health care outcomes rests.
The accountability conundrum becomes apparent in cases such as that of Dr Bawa-Garba in the United Kingdom. Here, the system pinned the responsibility of adverse health outcomes on the individual doctor, despite clear evidence that the doctor was working at the time in an environment which was deemed to be unsafe and unsupported. In Australia, Dr Kadota spoke recently about the exploitation that ultimately lead to her resignation as an unaccredited surgical registrar.
Toxic environments are not uncommon in health systems that fail to appropriately allocate responsibility, focus heavily on cost constraints, and show little regard for the well-being of health care workers. Meaningful and sustainable change is not possible where toxic cultures exist, and health system managers that do not have an ear to the ground may fail to recognise the cultural barriers to change. Further problems arise when, on meeting resistance, managers revert from the “carrot” to “stick” approach, and shift the dialogue more heavily towards compliance and audit rather than quality improvement.
The ‘hard’ approach may work initially, but when words such as ‘budget crisis’ enter the political dialogue, cynicism quickly takes hold and we begin to consider the reality that little has changed in health care in the last 30 years. Two questions then surface: Why now? And why me? Political leaders are challenged by these questions and so emerges a a culture of distrust. As we know, “culture eats strategy for breakfast”. We can not expect stakeholders to “buy in” without trust. As Dr Bartone stated of the My Health Record,
“Trust forms the cornerstone of our relationship with our patients. If that trust isn’t there, it does circumvent the exchange of information and the confidence.”
III. Clinician and Organisational Leadership
Collectively, we need to be clear on the direction we would like to take to move our health care system forward. This requires leadership from clinicians and organisations who are ready to accept that change is required.
It would be helpful to “map out how we can transform our health care system into a fit for system 21st century system that meets the needs and expectations of Australians” (AHHA, 2017).
The AHHA Blueprint for a Post-2020 National Health Agreement provides a solid perspective on how we can reorientate our healthcare system to focus on patient outcomes and value rather than throughput and vested interests. The blueprint, ‘Healthy People, Healthy Systems’, is available here.
For meaningful change to be possible, there is a need for “relentless hard work of local operational redesign, as described by Bohmer in his article, ‘The Hard Work of Health Care Transformation.‘ Practices such as Union Square Family Health in the United States demonstrate how this is possible, and have reorganised into multidisciplinary teams and restructured clinical flow to improve efficiency and continuity of care, enabled by the proactive use of electronic health record systems.
Numerous practices in Australia have adopted modern models of health care delivery, such as the Patient-Centred Medical Home (PCMH). Political will is also starting to shift in the direction of recognising, rewarding and creating the platform for value-based health care, however lack of financial investment and funding uncertainty remains a considerable barrier to whole-of-system change.
The RACGP ‘Vision for General Practice and a Sustainable Health Care System‘ has called for reorientation of general practice funding to support the medical home model, and is an important step forward for the profession. This view is supported by the AMA in its 2015 Position Statement. The Agency for Clinical Innovation has a valuable list of resources, including its own PCMH background paper, available here. WentWest Western Sydney Primary Health Network has a dedicated Patient-Centred Medical Home resource portal available on its website, available here.
A Fresh Change Management Approach
The article, ‘Clinical Transformation in Technology: A Fresh Change Management Approach for Primary Care‘ considers the barriers to, and facilitators of, clinical transformation in technology, and provides a new framework for getting health technology implementation right.
The CTT (Clinical Transformation in Technology) Framework, produced by Dr Nwando Olayiwola and Candy Magaña, is based in lessons acquired from successful electronic consultation programs and decades of experience in practice facilitation in primary care settings.
Clinical Transformation in Health Technology…applies implementation science, translational science and quality improvement principles to understand, prepare, groom, and nurture a clinical environment for success with any new changes, processes, models, innovations or technologies…while assuring minimal disruption to that environment.—
J. NWANDO OLAYIWOLA, MD, MPH (2017)
The Harvard Health Policy Review article explores change management concepts as they specifically relate to digital adoption in primary care, which is the authors’ field of expertise. The CTT Framework addresses the 7 key challenges in Telehealth adoption outlined in the article. These are:
- Staff training, skepticism, and fears;
- Lack of dedicated project management;
- Patient engagement and support;
- Technology and software problems;
- Partnerships and integration with the larger health system;
- Funding and reimbursement; and
- Long-term strategic planning
It is worth considering that in the Australian context, much of the resistance has been due to concerns about privacy, and both the RACGP and AMA have called for improved privacy provisions. The topic of privacy is further explored by Dr Edwin Kruys in his article, ‘It’s Not Just My Health Record We Should Be Concerned About’ and Dr Tim Leeuwenburg, ‘Why I am Opting Out of My Health Record – For Now‘.
A recent qualitative research study in Ontario, Canada has assessed the general public’s attitude towards users and uses of health care data held by the Institute for Clinical Evaluative Services (ICES). The study has found that whilst the public is generally supportive of this data informing research for the public good, there is no ‘blanket approval’ and health care organisations should engage with members of the public to understand and address their concerns regarding privacy and security, and ensure that research is aligned with social licence.
Political pressures add further complications. As Tony Abbott famously remarked,
“I have a lot of respect for the medical profession but we all know that doctors always err on the side of compassion.”
We could argue that all leaders need to lead with kindness and compassion, but perhaps underlying the statement is the need to consider capability and capacity building on both sides of the political equation. That is, the need for more doctors to spend time working in health policy and management, as well as the need for our political leaders to spend more time on the ground, listening to and understanding the issues that arise during the implementation phase of health technology solutions.
Whilst the traditional school of thought is that the direction of change is set from the top and filters down, increasingly in health care, significant change occurs through innovation and entrepreneurship. There are examples of this type of ground up change around the world, and the HBR article, ‘Transforming Health Care from the Ground Up’ explores this in detail. I urge you in particular to look at the case study on Iora Health outlined in the article. I had the great privilege to meet Andrew Schutzbank, Vice President Product and Technology, in 2017 and got the impression from our conversation of one of the most proactive and progressive health care organisations in the world. Visit the Iora Health website to learn more.
Dr Olayiwola and Ms Magaña touch on an ingredient that is largely missing in our current change management efforts in Australia. That is, practice facilitation. This is an approach used successfully by RubiconMD, and where Primary Health Networks such as WentWest have an increasingly significant role. Practice facilitation, such as with the assistance of the PHN Practice Supoort Team, can drive behaviour change, improve quality of care, gain patient and care team buy-in, and build capacity. This is made possible through the development of close personal relationships, and assisting practice teams to develop core capabilities in change management methodologies such as PDSA (Plan Do Study Act) cycles. You can learn more about WentWest Western Sydney Primary Health Network’s practice facilitation approach by reading the ‘Practice Development and Quality Improvement Framework.’
Read more about the CTT Framework here.
Whilst My Health Record implementation has been a mixed bag, there are important lessons that we can learn from the experience. Whilst some would argue that these are lessons that we should have learnt years ago when the PCEHR was being implemented, it is time now to carefully reflect on “what next”, consider frameworks such as CTT, and adopt a measured change management approach to take the best parts of My Health Record forward whilst moving swiftly to rectify its shortcomings in consultation with a broad network of stakeholders.