Challenges for Digital Leaders in the Era of COVID-19

The Young Executive Leader Initiative of the International Hospital Federation (IHF) is an opportunity for young executives from hospitals around the globe to meet with one another, discuss current trends and challenges, and offer perspectives from their experiences. This year, there are 17 leaders in the program, and the following group will be focused on digital enablement of healthcare and the challenges and opportunities of being a digital leader in a post-COVID world. You can find more information about our program here. This first article introduces you to our national and organizational perspectives on digital initiatives. 

Authors: Adroher, C (Spain), Almuntaser, S. (UAE), Bogues, R. (US and UK), Kuhlmann, L. (Germany), Staudt, J. (Germany), Tsai, M. (Taiwan) and Veloso, R (Portugal)

 

 

Portugal e-health intitatives

The healthcare system in Portugal consists of three coexisting systems:

1 – The National Health Service (NHS, or Servico Nacional de Saúde, SNS

2 – Special social health insurance schemes (health subsystems) that are occupation-based schemes used in the public sector and in certain professions such as police, military, and banking;

3 – Voluntary private health insurance.

The Portuguese Ministry of Health is in charge of managing the SNS. Similarly, it is almost free and available to all residents, including expats in Portugal. The system covers both primary and secondary healthcare services.

The digital transition is a priority for our government, mainly in public sector with the focus on citizens´ literacy, open data, interoperability, and digital tools that allows the access to all the clinical records across the whole health ecosystem (public, private and social institutions). In Portugal we have successfully developed, and driven during the COVID-19 pandemic, some telehealth initiatives and the implementation of IT systems and platforms to support the health information ecosystem, of which the following stand out (more details in www.spms.min-saude.pt and https://www.sns.gov.pt/):

The clinical registration software – SClínico. It computerizes and systematizes clinical records in primary and hospital care. It contributes to the records standardization, in order to guarantee the normalization of the information and to increase its quality. It enables the sharing of data among health professionals in different areas, thus contributing to a more effective, efficient and coordinated performance by the health professionals – at local and national levels.

The Live Health Data Platform (PDS Live), as a means to perform real-time video teleconsultations with the possibility of sharing information (for example, images and medical results) in clinical context, associated with an episode of provision of care.

The Electronic Health Record (EHR). It integrates the citizen’s contacts into the health system and leads to a single citizen’s clinical record. It allows gathering key information about each citizen that can be accessed by them, by the health professionals and by the entities providing the health services involved in their care. It enables a better management in terms of quality, safety and efficiency

The Citizen’s Area. Interface of services between the SNS and the citizen. It allows access to the RSE, making it possible to consult clinical data and results from medical examinations. It allows and encourages citizens to contribute with relevant information to complete their clinical records. It gives access to a set of services that previously forced the citizen to visits the health units. Examples of this are setting up an appointment with the family doctor, access to teleconsultations, asking for chronic medication prescriptions, access the digital vaccination record, the information on the waiting time for a surgery, among others. This is a highly relevant means to empower citizens in the active management of their health and to bring them closer to the SNS.

The Electronic Health Records – Referral (EHR-REF) – electronic system for referral among SNS providers. Supports deferred teleconsultation based on the clinical information in digital format.

The Medical Electronic Prescription (PEM) and The Paperless Exams project . Made it possible to prescribe and dispense medications and exams electronically. It, thus, allows the citizen to receive the prescription from afar and also creates conditions for the acquisition of medication and exams remotely.

The app MySNS and MySNS Wallet. It allows following the SNS news and receiving general notifications, including public health alerts. Through a logic of modular “cards” (examples: eVaccination Record, Allergy Record, Electronic Prescription), it allows citizens to customise their “portfolio” according to their needs and preferences.

Finally, Portugal defined these 6 issues as a reference for the elaboration of a more operational plan and, consequently, raised the need to characterize concrete measures for the strategic development of e-health in Portugal in the next years

  • Good governance and human capital development;
  • Ensure interoperability;
  • Infrastructure empowerment and information systems improvement in a national collaborative, citizen-centered health service;
  • Integration, continuity and proximity of health care;
  • Evaluation and sharing of best practices that promote innovation and ensure access, quality and efficiency of health care;
  • Continuous investment in innovation, research and development in order to generate, test and implement new ideas and solutions.

 

English and US digital initiatives

The English healthcare system is well known for its National Health Service (NHS), founded in 1948, which includes hospital, physician and mental health care funded primarily through general taxes. English residents’ use of the NHS is free at the point of service, and a small minority of the population purchases private medical insurance. In addition to 191 Clinical Commissioning Groups which govern and pay for care delivery at the local level, there are independent healthcare providers including independent hospitals and private General Practitioners’ and consultants’ practices. A summary of the English healthcare system can be found at the Commonwealth Fund.

At Cleveland Clinic London, we are setting out to build one of the most digital hospital in the UK. Cleveland Clinic is a nonprofit multispecialty academic medical center based in Cleveland, Ohio that integrates clinical and hospital care with research and education. Cleveland Clinic London will combine a nearly 100-year history and unique model of care with the best of the UK healthcare system. Our new hospital in London will bring Cleveland Clinic’s innovation and digital enablement to our patients in London. With over 80 IT applications, patients and providers will be offered a streamlined, accessible and robust experience to their care and their work, respectively.

Our focus on building these digital tools and technologies at Cleveland Clinic London complements the NHS’ Long Term Plan, published in early 2019, which highlights the importance of digital transformation. Later in 2019, NHSX was also launched, bringing together teams from the Department of Health and Social Care, NHS England and NHS Improvement, to drive digital transformation and lead policy and implementation.

For over a decade in the US, there has been a focus on digital transformation of healthcare. In 2009, the American Reinvestment and Recovery Act (ARRA) provided incentives to increase the use of Electronic Health Records, and in January 2011, the Patient Protection and Affordable Care Act (PPACA) went into effect in the US, which further emphasized the use of Electronic Health Records. In the subsequent years, there has been a tremendous interest and progress in the US and UK in enabling digital tools in healthcare. Our future articles will address these transformations in more detail.

In the UK and US, much like many other countries, COVID-19 has helped to accelerate the urgency and possibilities in digital transformation of healthcare. In the US, during the spring 2020, with the beginning of COVID-19, Cleveland Clinic saw a sharp rise in virtual visits as patients continued their care from the safety of their homes. At Cleveland Clinic London, virtual visits have always been part of our planned services for patients and are even more important now. Digital tools also include patients’ access to their charts and lab results, opportunities to message their providers with questions, perform administrative tasks online such as filling out initial health surveys, as well as providers’ ease of finding and inputting patient information, ordering diagnostic tests or viewing scans. COVID-19 may be shifting patients’ expectations of access to their care, and may be offering an urgency for consultants to become familiar with digital tools and communicating with patients through different technologies.

The Healthcare System of Germany

The healthcare system of Germany is organized as a multi-player healthcare system paid by a combination of public and private health insurances. Hospital funding in Germany is based on a dual-financing model. In effect the operation costs are borne by health insurances, whilst investments and building costs are provided by the Federal States, according to the Federal German Law of Hospital Financing (KHG).

Especially during the last years, the topic digitization gained importance to the healthcare system in Germany regardless of COVID-19. Digital health solutions offered as mobile apps are in high demand due to the growing number of smartphone and tablet users across all generations. In the psychiatric and psychosomatic field, digital solutions can be a valid supplement (i.e. video chats, apps, online tutorials). In addition, digital tools can facilitate patient treatment at home as well professionals can better respond to the needs of inpatients, outpatients and their relatives. Introducing those digital tools needs a special legal and financial framework. In Germany, the „Digital Care Law“ regulates the right of every patient for digital tools. In summer 2020, the first certified digital apps will be available for all patients in Germany.

The use and value of telehealth tools such as video consultations have grown during the COVID-19 pandemic in Germany. Due to the spread of the virus, the national health policy elevated the limitations on the number of cases and amount of services that can be provided via video consultations. Professionals can now use video consultation flexibly in all therapeutically relevant cases. New post-COVID-19 models of care delivery and reimbursement will need to be developed that maintain the broad use of telehealth services.

In the Vitos clinics, video consultations have been introduced in March 2020 within a short period. Until today, nearly 500 doctors use video consultations with patients on a regularly basis. In addition, so-called telepsychiatric concepts have been developed and implemented. In the coming months, video consultations as well as blended care treatment will be used as a continuous part of the treatment in the psychiatric and psychosomatic clinics of Vitos.

The Catalan Healthcare System and the Digital Health Strategy

The Catalan healthcare system provides publicly financed universal health coverage that is free at the point of access, thus ensuring that everyone who lives in Catalonia has the right to health care. It is a mixed model funded through taxes, with equal access to a wide range of benefits offered by a single publicly available network of health resources, not all of which are publicly owned. The network includes 160 providers, a range of organizations (eg, mutual societies, foundations, health consortiums) that have historically provided health care. One in four individuals in Catalonia has additional private health insurance, which does not forfeit their right to public health care.[1],[2]

This system, which dispenses services for 7.6 million inhabitants, gives a major role to community and primary health care and the use of information technologies and digital health. The large number of stakeholders had led centers to create their own IT systems to meet specific needs. As a result, in 2008, the decision was made to implement a common platform that can securely share clinical information between different centers and health professionals.[3] Shortly afterward, the personal health folder, a tool that allows members of the public to securely access their personal information and online services [4],[5], was deployed. Nowadays, Catalonia is a pioneer in the use of Information and Communication Technologies in public health care, has been considered a forerunner of eHealth adoption in Europe and is currently implementing a comprehensive digital strategy.[6],[7],[8],[9],[10]

The integration of the health information systems between primary care and specialized care allows for a fluid telemedicine-based case management. This implies relatively low coordination costs among different health specialties and incentivizes the use of these tools by health providers.

Just as their European colleagues, the state of alarm has forced to the Catalan Healthcare System to speed up the digital transformation of its centres: the confinement determined by the government because of the risk of COVID-19 spread during the regular development presential care services has changed radically all activities and the Primary Care assistance model eorienting it to a telematic mode (telephone, teleconsultation and videoconference) not only to the COVID-19 affected patients but to the entire citizenship. We present some of the following adapted measures.

Firstly, furthered improvements adjusting the already existent services’ access: the use of eConsulta has been activated for the total amount of care professionals equalising amount of face-to-face services. La Meva Salut has entered into force increasing the total amount of non presential care. The rate of citizens has surpassed the half million during the last month. As a result, the number of daily eConsultations during the first confinement month has increased five times the regular average. Nevertheless, the most significant increase is the telephonic attention.

The number of daily eConsultations during the first confinement month has increased five times the regular average. On the other hand, other service’s functionalities have also increased. Medication plans or other administrative tasks have been substituted by a telematic mode. Primary care visits compared to other care delivery methods in Catalonia for the period March 01, 2020, and April 19, 2020.

COVID-19 it will have evidenced the resilience of the Catalan public Healthcare System at the readapting itself to a digital healthcare model enabling a fast reaction to strike back the pandemic and softening sanitary emergency. Once the crisis would be over, it will be necessary to analyse every single tool deployed during this stage and attend to the lessons learned and consider the healthcare professionals as the true heroes who made it possible.

The Healthcare system in Taiwan

In Taiwan, we have National Health Insurance (NHI), which is a single-payer program with mandatory enrollment and low co-pays, operated by the government. [11]  Since instituted in March 1995, the coverage rate of this compulsory system has increased rapidly, reaching 99% of the whole population of >23 million by the end of 2004. [12]  The benefit package covered all necessary medical services, including outpatient, inpatient, dental services, traditional Chinese medicine, and prescription drugs.[13]

Information technology has been implemented in the management. Each beneficiary is issued an NHI card, with which they can access the medical system. Information of healthcare resource utility, such as diagnosis, medications, and procedures, is uploaded to a centralized data-bank for information sharing and for administrative purposes. 13

PharmaCloud System

Because of high healthcare accessibility in Taiwan, people may seek medical care in several facilities. Their medical records may therefore scatter in different institutions. To enhance patients’ medication safety, the National Health Insurance Administration (NHIA) set up the patient-centered “NHI PharmaCloud System” in July 2013. [14] After dual-card verification (i.e. the medical personnel’s card and the patient’s NHI card) with a special card reader which contains a verification chip, a medical professional can access the patient’s medication records over the previous three months in the system. Authorized medical institutions may also batch-download the recent medication history of patients who have made appointments to facilitate the reading process and various utilities. With the batch-downloaded information, medical institutions can prevent double dosing of the same medication and serious drug-drug interactions to improve patient safety. In recent years, the NHIA is trying to enrich the information in the PharmaCloud, asking medical institutions to upload information such as records and reports of laboratory examinations, radiological and imaging examination, pathologic examinations, and special examinations (such as endoscopy), as well as the medical images.

As coronavirus disease 2019 (COVID-19) became epidemic, the Ministry of the Interior National Immigration Agency provided the immigration information and the NHIA uploaded the information to the PharmaCloud System. [15],[16] Medical institutions were then able to check the travel history via the system as a quarantine measure, and some institutions even developed their own quarantine system with the batch-downloading function.

My Health Bank

A personalized cloud-based service, “My Health Bank” system, was launched on September 25, 2014. This system released parts of personal medical records to the beneficiaries.[17] People can conveniently access their own latest medical information and insurance status using their “citizen digital certificate” or “password-registered NHI card.” This may empower people to more direct control of their health and narrow the information gap between doctors and patients.

As COVID-19 became epidemic, the government controlled the selling of face masks. People were able to order masks via the Named-Based Mask Distribution System, which was closely related to My Health Bank system.

Electronic Medical Records

In 2012, the Ministry of Health and Welfare (MOHW) launched the EMR Exchange Center (EEC), a platform through which medical facilities could exchange specific parts of electronic medical records (EMRs) in a common format. It originally contained information of ambulatory medical records, ambulatory prescriptions, discharge notes of inpatient care, reports of blood examinations, medical images, and reports of medical images. In recent years, the EEC gradually included more information such as operation notes and notes of emergency department visits.

The health sector in the United Arab Emirates (UAE)

The UAE has a comprehensive, government-funded health service and a rapidly developing private health sector that delivers a high standard of health care to the population. Healthcare is regulated at both the Federal and Emirate level. Public healthcare services are administered by different regulatory authorities in the UAE including the Ministry of Health and Prevention, Health Authority-Abu Dhabi (HAAD), the Dubai Health Authority (DHA) and the Emirates Health Authority (EHA).

Health care is provided for all nationals and health insurance is mandatory for non-nationals. Total expenditure on health was on average per capita expenditure of US$ 1078.

The 2021 vision of the UAE commits the Government to ensuring universal access to health care services by all Emiratis through availability and equitable accessibility of excellent health care services and personal care services in order to fulfil citizens’ growing needs and expectations. The UAE Government is committed to providing world health class healthcare services by improving governance in the healthcare system and pursuing the accreditation of hospitals and healthcare providers in the UAE as well as upgrading the standards for healthcare professionals.

The UAE is party to the revised International Health Regulations (IHR), which entered into force in 2007. However, there are still areas to improve in national core capacities for IHR implementation in the areas of legislation, coordination, surveillance and response, preparedness, risk communication, laboratory, points of entry and readiness for zoonotic, food safety, chemical and radiation events.

Health Care Transformation in Dubai

In Dubai, healthcare is experiencing rapid innovation through modernization of patient service delivery and infrastructure projects. The Dubai Health Authority serves a dual role as regulator and operator of the Emirate of Dubai’s healthcare sector. Priorities for the health care sector in Dubai include retaining and attracting high caliber medical and healthcare staff, strengthening initiatives around postgraduate healthcare education and continued investment in primary and specialized health services.

There are also two healthcare free zones in Dubai, Dubai Healthcare City and Dubai Biotechnology and Research Park, which have their own regulatory bodies. Dubai Healthcare City (DHCC) was launched in 2002 to meet the demand for high-quality healthcare, today DHCC has two hospitals, over 120 outpatient medical centers and diagnostic laboratories with over 4,000 licensed professionals. Dubai Biotechnology and Research Park, launched as part of Dubai’s 2010 vision to establish a knowledge-based economy, is the world’s first free-zone dedicated to life sciences.

Salama Program – Dubai Health Authority Electronic Medical Record

The Dubai Health Authority (DHA) was reformed, in June 2007, with an expanded vision to include strategic oversight for the complete health sector in Dubai and enhance private sector engagement. DHA’s aim in Dubai is to provide a smart, accessible, effective and integrated healthcare system, protect public health and improve the quality of life within the Emirate. Keeping the strategic plan in mind, the DHA’s mission is to ensure access to health services, maintain and improve the quality of these services, improve the health status of nationals, residents and visitors and oversee a dynamic, efficient and innovative health sector. Prior to 2015 DHA renewed major parts of the legacy Hospital Information System (HIS) known as SAM, Pharmacy application (iSoft) and application integration engine. In 2015, DHA embarked on its transformation journey to replace its legacy systems with a state of the art Electronic Medical Record (EMR- Epic) and Orion Rhapsody Application integration engine. These systems shall be used at all DHA hospitals and clinics. Additionally, DHA also began to enhance customer experience through digitization. The customer experience enhancement was achieved through implementation of Microsoft Dynamics CRM, and mobile applications which were separate projects that ran in parallel to allow for systems to integrate and complete the customer experience. In February 2016, “Salama” Dubai Health Authority’s Electronic Medical Record was inaugurated. Salama is a DHA-wide project that aims to provide patients and doctors access to medical records through a patient portal and ensure that the electronic patient medical record is available across the DHA health facilities. So far more than 1.4 million DHA patient medical records and more than 12 million transactions have been transferred to the Salama system.[18],[19],[20]

Conclusion

According to our national perspectives and professional experiences, it appears that digital and leadership challenges we all face are very similar, and have only accelerated and become more important during COVID-19. Making user experiences’ easier and more equitable for all, improving professionals’ adoption, improving patients’ literacy, improving cybersecurity, data security and data protection, improving interoperability of the systems, etc. – these are the main challenges for digital leaders.

Our future articles will be centered in these 3 themes:

1 – Is this COVID-19 pandemic enough for the successful improvement of Citizen’ and Healthcare Professionals’ Engagement to e-health?

2 – The importance of legal and regulatory frameworks in healthcare information systems – who needs to be heard?

3 – About the lack of interoperability and data protection:  What has to happen to change it?

We’ll also use quantitative and qualitative surveys from IHF members to help provide more data for how these themes are impacting healthcare across the globe. The results of the surveys will give a broad overview regarding different topics in the field of context digital tools (i.e. barriers and changes of digital health, patient engagement, standardization and interoperability). In addition, the results will offer concrete as well as practical answers for integrating digital tools into healthcare systems.

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[13] Universal Health Coverage in Taiwan.  https://www.nhi.gov.tw/DL.aspx?sitessn=293&u=LzAwMS9VcGxvYWQvMjkzL3JlbGZpbGUvMC8xNjEwNC8yMDE4MDYwOF91bnZlcnNhbGhlYWx0aGNvdmVyYWdlLnBkZg%3d%3d&n=MjAxODA2MDhfVW52ZXJzYWxIZWFsdGhDb3ZlcmFnZS5wZGY%3d

[14] PharmaCloud System. https://www.nhi.gov.tw/English/Content_List.aspx?n=02BA04454AED80E0&topn=BCB2B0D2433F6491

[15] Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. Published online March 03, 2020. doi:10.1001/jama.2020.3151.

[16] Juang SF, Chiang HC, Tsai MJ, Huang MK. Integrated Hospital Quarantine System against COVID-19. Kaohsiung J Med Sci. 2020;36(5):380-381.

[17]My Health Bank https://www.nhi.gov.tw/English/Content_List.aspx?n=21D194F3C675DB0E&topn=BCB2B0D2433F6491

[18] ColliersInternationall|AcceleratingSuccess|www.colliers.com/engb/unitedarabemirates/services/healthcare

[19] https://www.dha.gov.ae/en/DHANews/Pages/DHANews619602078-09-04-2017.aspx

[20] https://www.dha.gov.ae/Documents/Dubai_Health_Strategy_2016-2021_En.pdf

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