This appeared a few days ago:
Five minutes with Mitchell Burger
This month we spent five minutes with Mitchell Burger, Director Strategy, Architecture, Innovation and Research, ICT Services, in Sydney Local Health District.
- Introductory stuff omitted.-
What do you think will enable digital health projects and
innovations to succeed?
We are about to start consultation to develop our district’s new 5-year digital
health strategy, and have done a little thinking on this, so here is a long
(sorry!) list of bullet points. We’d really love suggestions.
- Genuine partnership with clinicians and the community in the codesign and implementation of new, digitally-enabled models of care – something akin to the Yolngu concept of Ganma
- Focusing on workforce development as a priority over technology – both building specialisations like informatics and data science and analytics, and also upskilling and promoting the slow and steady process of cultural change across the broader workforce
- Carving out protected time and spaces for clinicians to reimagine workflows and design and iterate new models of care in partnership with digital health disciplines
- Re-apportioning of government and health service budgets into digital infrastructure and transformation programs, commensurate with its emerging criticality and contribution to population health and growing business value (say, by benchmarking investment in digital as a proportion of CAPEX and OPEX to other sectors). And mimicking, say, long-term investment models like justice reinvestment and NZ’s welfare budget.
- Inclusion of sustainable funding mechanisms for new models of care by design, upfront
- Research operationalisation and streamlining innovation and procurement pathways, to accelerate research translation and give proofs of concept and pilot projects defined and well-trodden paths to production and scale
- Fostering and continuing to develop expertise in implementation science within regional health services
- Investment in foundational digital infrastructure (esp. data systems infrastructure) and institutional competencies that will enable a longer-term transition to value-based care and away from activity-based funding, and also enable us to leverage emerging AI and automation technologies
- Piloting regional commissioning partnerships between LHDs and PHNs using pooled, blended capitation and outcomes-based funding mechanisms (e.g. like the Prevention and Chronic Condition Management Funds (PCCMF) recommended by the Productivity Commission)
- My view (and I’m open to feedback!) is that we should reconsider interoperability as a microeconomic challenge, rather than a technical one, and that health services could accelerate interoperability through taking a much harder line in procurement and leveraging our near-monopoly market positions to instigate standards adoption and promote use of digital solutions like eRef, My Health Record, secure messaging, etc. within regional digital ecosystems
A final thought: I think that hospital districts, together with PHNs, are uniquely placed through their scale, community and cross-sectoral partnerships, public trust, and sovereignty over clinical and data governance to be at the forefront of digital transformation.
What do you think are the biggest challenges facing digital health
at the moment?
Digital health is of course very hard, and there are many challenges, so it
takes resilience and energy. Here is another long list of some immediate
challenges – again, we’d be delighted to receive suggestions for how to address
these, so please reach out.
- The sheer complexity of implementations, and the speed of technological development
- Poor, stagnant design and usability of clinical information systems, which don’t meet modern digital service standards
- Hype, and an overly future-oriented mindset beset with management jargon and technocrats (like me I have to admit!) chasing the next idea rather than seeing things through
- Disillusionment resulting from unfulfilled promise and overly optimistic digital and ICT business cases
- Eroding social licence for use of health data
- Legacy funding models which do not reward and foster innovation
- Data availability and data quality
- Institutional competence in data governance, privacy and cyber security
- Ambiguity in roles and responsibilities for digital initiatives between the different levels of government
Do you have any interesting resources or helpful networks people
should know about?
For those interested in some of the issues surrounding the use of AI – I think
the AI
Now Institute is a fantastic resource. And I have a huge Endnote library
full of reports and articles on AI, only a very tiny fraction of which I’ve
actually read (optimistically I try to think of it as an antilibrary!),
so I’d be happy to share this too.
Connect with Mitchell via LinkedIn
Here is the link:
https://dhin.net.au/five-minutes-with-mitchell-burger/
Isn’t nice to read about Digital Health from someone who does not think that more adoption of the #myHR is the answer to everything. Clearly the brainwashing can wear off!
David.
Isn't is a contraction of ... is not ..
ReplyDeleteWhat does this mean "Isn’t nice to read about Digital Health .... "?
Do you mean:
Is not this nice to read ... or
Is not it nice to read .... or
It is nice to read .... which seems clean and unambiguous.
Clarified
ReplyDelete.... we should reconsider interoperability as a microeconomic challenge, rather than a technical one, ....
ReplyDeletewhat the heck does this mean?
Oh, I see, according to LinkedIn he has a BCom (Hons I) in Marketing and Econometrics and lots of experience in NEHTA and ADHA.
That explains a lot.
David,
ReplyDeleteI agree with the intent of the author's comment that interoperability should be seen in the light of the microeconomic challenge that it reflects.
Interoperability is the language of the technology sphere.
In the human social and economic sphere the microeconomic challenge is to be able to receive meaningful and accurate information in a timely and effective fashion in order to take appropriate action. That action can have effect in improved safety, quality and efficiency. And, this points to the microeconomic reality that the current concept of productivity deriving from manufacturing has a much more limited domain of relevance.
The author said:
ReplyDelete"...interoperability as a microeconomic challenge, rather than a technical one..."
which is different from
".. interoperability should be seen in the light of the microeconomic challenge that it reflects..."
"in the light" means that "microeconomic challenge" is one of many considerations.
"interoperability as a microeconomic challenge" is not the same thing.
... "this points to the microeconomic reality that the current concept of productivity deriving from manufacturing has a much more limited domain of relevance."
ReplyDeleteErrhmm .. I hope you won't be too offended but that is just a lot of words with no clear meaning.
It's the sort of stuff a politician or bureaucrat would splutter forth and the recipient would look blank for a moment or two then say, "yes of course"; all the while thinking, "I don't really understand what the poor chap is trying to say, but it sounds impressive so it must be good".
Once upon a time, when clear English was taught in schools, the author might have said:
"The microeconomic reality is that, within the manufacturing environment, the current concept of productivity has a much more limited domain of relevance in comparison to --- .
In response to Anonymous 11:12AM and 1:50PM, I draw attention to the following comments made by Megan Quinn, Deputy Secretary Treasury Department speaking at the Global Forum on Productivity held in Sydney in June, 2019.
ReplyDeleteMeghan Quinn stated:
1. Productivity remains a somewhat mystical and intangible element of economic analysis
2. Health policy makers have embraced the concept of integrating the actions of, and information from, the different parts of the health and community sector to provide care suited to the personal circumstances of the patient—‘integrated patient-centred care’
3. The Productivity Commission’s concept is that integrated patient-centred care involves the entire health care system
4. An integrated system must deliver customized services to people, but its processes must be highly organized to provide consistency and to reduce costs
5. Australia’s progress towards an Australia-wide integrated system of care across the primary, hospital and other sectors has been poor, hampered by weak information flows and coordination, inadequate attention to the experiences of patients, and flawed incentives and fragmented governance arrangements
6. An integrated approach to care should concentrate most on those whose health conditions are critical and for whom the returns will be greatest in terms of better health outcomes and lower health costs
I trust the above comments are helpful.
The comments @6:42 AM are interesting, ? helpful. Although few would dispute the concept that “integrated patient-centred care involves the entire health care system” is it not reasonable to ask - ‘so what’?
ReplyDeleteWhile development of a nation-wide integrated system of care across the primary, hospital and other sectors is a noble aspiration surely it is fair to say that (and I stand to be corrected) Australia is not that much different from anywhere else. Where in the world has this been achieved? Once again, is it not reasonable to ask – ‘so what’?
Yes, weak information flows and inadequate coordination have hampered development of an integrated system of care across multiple sectors. Accepting that this is the situation prevailing today, in Australia and elsewhere, it leads one to ask – ‘so what’?
What is being done (or can be done) to change this situation in Australia?
Changing an entrenched system of practice is inordinately difficult, barriers to change are high and resistance is great. A national approach is bound to fail. If that is so then what approach has a reasonable chance of meeting with success, and if and when it can claim success will it be embraced more widely, or will it be resisted until it withers into oblivion?
I trust the above comments are helpful.
I agree with much of what @3:05PM has said.
ReplyDeleteMy first aim was to address the 'productivity' issue from my earlier comments. Historically, politicians, governments and senior health and treasury bureaucrats have relied upon productivity-based arguments to advance all manner of solutions to health care's challenges.
Meghan Quinn has effectively cast the 'productivity' argument aside.
The question of what concept is to replace productivity remains an open question.
As far as the remaining comments made by Meghan Quinn go, they reflect the nature of the national and indeed global conversation about the longer-term direction of healthcare reform and point to a few of the current impediments.
Meghan Quinn's 2nd comment, especially its phrasing, is important.
Integrating the actions of, and information from, different parts of the health can community sector requires clinician leadership. Clinicians need to work through how they want to work together in order to address chronic care, for example. Solutions for these opportunities will not be found through organization-centric thinking and acting.
And yes, changing entrenched practices is difficult; particularly if the clinicians themselves don't take responsibility.
Equally, the acquisition and imposition of hospital-centric technology solutions makes the work all that much more complex and arduous.
As far as what can be done to change this situation in Australia, we need first to look for examples where success has been achieved. We need to learn the lessons and then determine where and how these learnings can be scaled up. A little honesty from current health leadership that they don't know how to go forward would be helpful.
The more challenging question is whether their is an appetite for such reform.
John asks, “Is there an appetite for such reform?” The crucial word here is ‘such’.
ReplyDeleteWhen NeHTA was established over a decade ago there was an ‘appetite’ for reform aimed at providing a more integrated health care system. Over time appetite for reform waned and NEHTA failed.
Productivity-based arguments and cost-saving claims were used to convince those politicians, governments and senior health and treasury bureaucrats to whom John refers to provide the funds which led to the formation of NEHTA, and subsequently the ADHA and My Health Record, incurring a huge expenditure of tax-payers’ funds which eventually culminated in nothing much being achieved.
The enthusiasm for reform, while genuine was sadly misplaced, because the advocates never really understood what they were trying to achieve, let alone how to achieve it. John’s very valid comments above reinforce this view.
So too does his comment that “integrating the actions of, and information from, different parts of the health and community sector requires clinician leadership”. These crucial words lie at the heart of the essential issues that need to be resolved before real reform of the healthcare service delivery model will be realised. And central to this (as you observe) is the deeply complex cultural issue that “clinicians need to work through how they want to work together”.
Given we agree that the above holds true we have now arrived at the nub of the problem – “what can be done to change this situation in Australia”.
You suggest that “we need first to look for examples where success has been achieved”. That is a good place to start, and in doing so we need to learn the lessons illuminated by those examples and then determine where and how these learnings can be scaled up.
Can you please provide a list of 3 to 5 examples where success has been achieved.
I'm not aware of any, but if they do exist they must be very small, and still in their infancy with a long haul ahead to become relevant enough for clinicians to want to embrace.
Deleteif there are any other success stories, they would need to be in a similar geo-political/health system environment.
ReplyDeleteLet's see. How many countries are there of 25 million people, that have a similar land mass, have a federal system with about ten states, each with its own legal system and have a combination of public and private health systems?
Good luck finding one, never mind one that has an integrated health system we can copy.
@10:38 PM I think you have missed the point entirely. A small ecosystem involving sharing of information over an integrated system of clinician-aligned workflows is what is under discussion here.
DeleteTo begin with let me respond to @1:19PM.
ReplyDeleteI have one really good example that is up and delivering improved healthcare for its catchment population. This is the Renal Network serving the ACT and adjoining Southern NSW Local Health District. The value is apparent to the stakeholders. I have to disclose that I am a renal patient and I have been actively involved with this initiative for over 10 years.
I have to go back to the 1990s when I led the national initiative called "Moving Information to Care" to find other examples. One of the initiatives was the creation of the Poison's Information Network. The fruits of this initiative are readily apparent; just look at the packaging of poisons to see the reference to the national telephone number 131126. That was only possible because the individual poison information centres agreed to cooperate and an administrative mechanism was created to address the call and cost shifting associated with transferring a call according to the cultural rules of the cooperating poison information centres. For example, NT calls are transferred first to South Australia and only transferred to another state if SA can't respond to the call.
Returning to the core question, since there is no focus on such achievements there is no immediate way to say how many reforms have been successful.
The hidden resource that we can tap into is the pool of clinical services and their leaderships that would like to operate differently BUT don't have a way to go forward. Where do they turn to for assistance? Network-centric thinking and acting throws up these conundrums.
I disagree with the comment made by @10:38PM. This is not about copying someone else's health system solution. This is about evolving our own healthcare system according to the values Australian's hold dear.
The Chair of the Productivity Commission, Michael Brennan, has made a number of important observations in speeches over the past few years:
a) Any policy reforms to healthcare have to start with the realistic premise that there is no big bang reform that is going to get us where we want to go in a short period;
b) the real benefit of the 'reform' (referring here to the experience of the 80s and 90s) was the process that followed on from that initial decision;
c) The burden of disease has shifted, and continues to shift, to chronic and complex conditions, like diabetes, cardio vascular disease and mental illness;
d) There may be big gains from technological breakthroughs, but it is also likely that we will need a different sort of innovation—one focused on changing systems, funding strategies and business models. He added, that in many ways, these innovations are as hard as the ones involving cutting edge scientific breakthroughs, given that they must contend with the complex world of human behaviour and public systems.
e) Everyone agrees that we want an integrated, patient-centred health system; the task is as much tactical and strategic as it is intellectual. The main question is how to get traction—to build and maintain some momentum?
@8:31
ReplyDeleteI thought that what was under discussion was point 5 in the article David blogged
"5. Australia’s progress towards an Australia-wide integrated system of care across the primary, hospital and other sectors has been poor, hampered by weak information flows and coordination, inadequate attention to the experiences of patients, and flawed incentives and fragmented governance arrangements"
That's hardly a "small ecosystem"
@9:24AM John's comment @8:22AM synthesises the central tenet of the discussion which should clear up your confusion.
ReplyDelete@8:22AM John said "(e) Everyone agrees that we want an integrated, patient-centered health system".
ReplyDeleteIf everyone agrees there should be no problem getting traction and building momentum.
A good system, even an exceptionally good system, located in an isolated pocket of committed people, will remain stagnating where it is, unless or until you commit the necessary resources required to breathe life into it to get it off the ground. Surely that's not too difficult to understand.
I would suggest that "the main question" is not "how to get traction" but rather - what are you doing about it? Do you have a business plan? Do you have a strategic and marketing plan? Do you have a funding proposal? Or are you still pondering possibilities?
"How to get traction?" in the health domain with a 'new system approach' centered around 'reform' is a really difficult challenge.
ReplyDeleteThe Renal Network sounds interesting and may have some potential to catalyse a nidus of reform. But would that be sufficient to be embraced by multiple health cultures notoriously resistant to change and by a risk averse bureaucracy riddled with flaky politics?
In regard to @12:43PM, the point (e) was made by Michael Brennan, Chair of the Productivity Commission. The Productivity Commission is a federal body and speaks for itself; it does not speak on behalf of the health sector.
ReplyDeleteMichael Brennan raised the issue of getting traction and building momentum because they know from history how difficult it is to move beyond nationally agreed directions to actually translating that into action.
I agree that there are a range of practicalities to be addressed. First and foremost, if you accept the PC's proposition that the challenge is to provide a mechanism to get traction and build momentum is who do you approach? The challenge is to have a mechanism that can be seen to be nationally relevant and at the same time carry that relevance to the level of healthcare service delivery and on to address the digital sphere. (Interoperability is no substitute for doing the hard clinical yards and addressing the barriers to moving forward. Vendor business models are just one of the impediments.)
Equally, it is necessary to provide evidence that the approach you suggest has actually delivered the sought after stakeholder benefits. This evidence has to speak to a variety of stakeholder agendas with the potential to gain scale effects. The approach equally has to open up the horizon for new service delivery models to emerge and gain traction.
None of this is easy and if governments actually knew the way forward we would not be having this type of conversation.
As far as what I am doing the short answer is engaging with others who recognize the need for change and sharing ideas and understandings in order to advance the nature and level of discourse.
@4:33 PM That all makes a lot of sense as do the preceeding comments. It's also both reassuring to learn that there is at least one "really good example" (Renal Network) which can demonstrate what can be achieved along the lines being discussed.
ReplyDeleteBy the same token it's also a little troubling that a couple of other model examples have not been nominated! Perhaps they don't exist!
Engaging with others and sharing ideas and understandings is a necessary and worthwhile activity, provided it is underpinned by something more and not just 'talk'; and it needs to be backed up with a clear well-documented plan that plots the way forward.
Very often that is the hardest thing to do in a hugely complex environment like healthcare, but it must be done if the project is to find the political and investment support needed to take it forward.