Why do countries struggle with healthcare digitalization?

In Europe, consolidation and centralization seem to be enablers of digital transformation in healthcare.

Sep 30, 2024

This is a newsletter of Faces of Digital Health - a podcast that explores the diversity of healthcare systems and healthcare innovation worldwide. Through interviews with policymakers, entrepreneurs, and clinicians, listeners gain insights into market specifics, go-to-market strategies, barriers to success, characteristics of different healthcare systems, and the challenges and access issues in healthcare. Find out more on the website, tune in on Spotify or iTunes.

In 2010, Portugal, a country of 10 million, centralized healthcare IT decision-making at the national level by establishing SPMS—a shared services organization within the Ministry of Health. SPMS not only sets the direction for digital health transformation but also builds and manages IT solutions.

In 2018, NHS England started several projects aimed at creating single care records in different areas around the UK. The projects called Local Health Care Records Exemplars are run in London, Manchester, Yorkshire and Humber, Wessex, and Thames Valley and Surrey. For example, One London, connects 42 NHS trusts, five integrated care systems, and 1,400 GP practices.

Recognizing the need for streamlined decision-making, the NHS replaced over 200 commissioning groups with 42 Integrated Care Systems (ICS) in 2022 to enhance healthcare procurement.

Consolidation drives better data exchange.

Let’s look at one more example in Europe: In 2017, CatSalut - Catalan Health Service, published a Master plan detailing the next steps in the development of healthcare digitalization for Catalonia’s 7.6 million residents. It mandated the use of openEHR data specification for all future applications to create a future-proof, data-persistence-focused layer. This decision took away some autonomy from healthcare providers who were up until that point, free to choose what type of healthcare software they wish to use. Variety in software means variety in healthcare data standards used and hence challenges with interoperability. The decision to mandate openEHR aims to enable patients to have a comprehensive healthcare record with all their health data in a structured format. That’s the aim for Catalonia by 2030, says Jordi Pierra Jimenez, Director of the Digital Health Strategy Office at the Catalan Health Service. Further more, Spain aims to take a similar path on the national level (see the full explanation in the video).

A common thread in these three examples is a recognition that the market can’t regulate itself and if we want to connect and enable easier flow of healthcare data more broadly, on regional, national, and cross-border levels, it has to be done by policy first.

Why does data standards unification matter?

Technically, systems can integrate using messaging standards for data exchange. However, in practice, each integration is time consuming and somebody needs to pay for it. Vendors don’t integrate just because it’d be good for healthcare.

Second, the examples above show that a broader change requires defined decision makers. You know how when you have 10 colleagues involved in an email chain, and no one reacts because everyone expects someone else to do the first step? That’s how healthcare collaboration and data exchange can easily get stalled because everyone is waiting for others to start interoperability efforts. This is the commonly mentioned role of EHDS - it’s the usual suspect that gives governments an excuse to mandate specific healthcare data strategies on national levels, dedicate funding to support healthcare IT investments, etc.

Why is digital transformation unpopular for decision makers

Healthcare IT is very complex. Development, especially when done with clinical engagement, takes time. Hospitals need robust infrastructure: good network coverage, high-speed internet, and reliable hardware. Without these, software can be slow or buggy, frustrating users and impeding adoption, and in addition frustrating vendors, because they can’t do anything about the suboptimal end result.

Why does this matter in the broader political context? For policymakers, tangible investments like new hospital buildings or CT machines have more visible impact than digital transformation, which is why digitalization often isn’t a priority. This is especially true in smaller countries, where fear of failure can deter long-term investments.

France, Catalonia and even Germany are ambitiously stepping on new paths with grand ideas and digitalization promises. But ask any Germany about digitalization in healthcare and they will grunt with dissatisfaction. Digitalization is a slow process.

All the challenges countries and ministries need to overcome

Governments face numerous challenges in digital healthcare transformation. They need to have good experts who care more about public service then their own pockets. Ministries need to know what they want and articulate that in detail. This is where consultants often come in. They prepare a strategy… and then leave. As mentioned by Mehdi Khaled in a discussion about consultancy in healthcare, one of the bigger challenges for governments and ministries is the lack of knowledge transfer between consultants and local workforce that would make strategies more easily executable. Strategies can end up shelved, or governments might need to keep paying consultants to make progress. Other challenges for governments, include:

Defining the problem correctly: Often, the problem is ill-defined, leading to suboptimal solutions. If consultants come in when the problem is already defined, they can have a harder time making meaningful impact on a project.

Measuring impact: There's often a lack of clear metrics to measure the impact of digital health initiatives on overall health outcomes.

Vendor management: Governments often struggle to evaluate vendor claims and ensure that technologies are appropriate for their specific context.

Limited budgets and timeframes: Governments often have to work within electoral cycles or limited budgets, which can lead to short-term thinking.

Lack of accountability: Many healthcare systems lack clear accountability structures, making it difficult to implement and sustain changes.

Healthcare data potential vs. reality

It’s fairly easy to understand the dream version of the healthcare of the future: data available to patients and providers regardless of where they seek care, personalized care based on all past patient experience and medical history. The challenge is in HOW to get there. August and September episodes of Faces of digital health focused on several aspects of digital transformation strategies in healthcare: from hospital level with Anne Forsyth, Director of Clinical Applications and Support at Women’s College Hospital in Canada, exploring regional care coordination with Jordi Pierra Jimenez, and national strategies and considerations with Cátia Sousa Pinto, Head of Global Digital Health and International Affairs at SPMS - shared services of ministry of health of Portugal. And to add a broader view to that Mehdi Khaled, Managing Partner at Seha consultany, shared what governments struggle most when creating new digital health strategies.

Key things Ann Forsyth recommends hospitals is this:

Have a data governance structure in place. Data standardization, defined data stewardship, data access and control, quality management and cybersecurity are fundamental for success.
Relationships are key to success. This refers to successful implementations, which requires buy-in from the end users, training, mindful workflow design. Properly designed workflows and effective training help reduce the administrative burden on already overworked healthcare providers. Workflow issues need to be addressed upfront, since it is easy to put in place a bad workflow but incredibly difficult to change it once thousands of users already adopted it.
Look for gradual improvements. Large-scale change can be overwhelming. Start with a smaller scope, and always compare the before and after effect. When mapping workflows, Anne’s team started with registration and check in. They divided the project in smaller chunks to be able to test the best practice and training. Further moto is: keep improving, keep optimizing, keep standardizing.

This advice is valuable for other organizations too. FHIR has been instrumental in driving excitement about interoperability. In Europe, openEHR data specification is gaining momentum in the NHS, Spain, Sweden, Slovenia, and beyond.

I’ll be further reporting about this from the openEHR conference, taking place in November in Reading, UK. :)

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