Oireachtas Joint and Select Committees
Wednesday, 14 September 2016
Select Committee on the Future of Healthcare
Future of Health Care: eHealth Ireland
I welcome Mr. Richard Corbridge, chief information officer of the HSE, to our meeting. He is accompanied by Ms Yvonne Goff who is the HSE's chief clinical information officer. I thank them both for coming along and also welcome Mr. Ray Mitchell.
I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House, or an official by name or in such a way as to make him or her identifiable.
I apologise for the delay; we had a long earlier session. I invite Mr. Corbridge to give his opening statement.
Mr. Richard Corbridge:
I thank the committee for the invitation to attend this committee meeting. I am joined by my colleague, Yvonne Goff, who is the HSE's chief clinical information officer, a role recognised globally as key to enabling the delivery of digital solutions in health and to maintaining a clinical focus in the delivery of digital solutions for how we put forward what we do. The work being done in Ireland around clinical engagement has been recognised by the European Union, the World Health Organization and the NHS as having world class clinical engagement and leadership in many of its digital projects. This is a crucial foundation to the digital journey we are on today.
I will first clarify the concept of eHealth Ireland in relation to the Health Service Executive. It is a function created out of the eHealth Ireland strategy of 2013. This document was provided to the committee previously by the Department of Health in an earlier submission. Today, eHealth Ireland is a function within the HSE tasked with bringing about a change to the way in which health care is delivered in Ireland through the use of digital solutions. The documentation that has been provided to the committee ahead of this meeting will give it a comprehensive view of what and where the delivery for the eHealth Ireland programme has got to over the last 18 months. These documents include: Ireland's eHealth, a progress document that sets out key successes that have been achieved and provides a summary of the focus for the next 12 months, highlighting priority areas throughout the health system, and the Knowledge and Information Strategy, a plan formulated and agreed across all stakeholders in March 2015. This document sets out an organisational design which created a national programme delivering digital benefits into health throughout Ireland. In addition, there is a pack of ten slides which give the committee some pictures to explain some of the things we will go through as part of this opening statement.
The development of the knowledge and information plan is not simply another health-based strategy. Its agreement and implementation has enabled us to move forward at a rate not seen before in digital health in Ireland. It has enabled us to consider what digital means to health care specifically in Ireland, learning from other jurisdictions such as the USA, the NHS in the UK, Northern Ireland, Estonia and Australia, where success has been achieved in some arenas and where significant lessons have been learnt in others. The delivery of digital solutions supporting health care is described in the knowledge and information plan. It has enabled the HSE to put in place a national team to deliver solutions to the whole health system. It removes a previous focus on acute hospital solutions and places at the heart of health care delivery the ability to centre what we do with digital on the health system, not the health care definitions and boundaries but putting the patient at the centre of everything we do.
Digital solutions deployed to the health care system are immune to organisational structure and change. They are put in place to empower the patient to choose where they want to be treated and to neutralise the current boundaries of health care. Effectively, digital solutions can be seen as a catalyst to the delivery of integrated and personalised care. "No more IT projects" is the mantra of eHealth Ireland. This may seem somewhat strange but it is a key lesson learnt from previous attempts to deliver large digital solutions in health in Ireland. What do we mean by "No more IT projects"? We mean everything that digital can do, whether it is a new financial management system or an electronic health record for community functions around Ireland, has to be more about the business change than the technology. Digital solution should not change the way people work. We need to do that through development of business change facilitated by digital.
The knowledge and information plan defines the resources, both financial and human, needed to do this and a timeline to enable it.
All targets set in the plan in the spring of 2015 have thus far been met, which is a credit to the eHealth Ireland team and its collaboration with the Department of Health. The success of 2015 has released a small amount of additional funding to the HSE in this area after over a decade of what is considered to be under-investment.
Building on a change that has seen some success provides Ireland with a unique opportunity to apply lessons learned from elsewhere and move forward safe in the knowledge that others have proven the direction Ireland can take. Now is not just a safer time to invest in digital solutions for health, but an essential time. The integration of care, the removal of false boundaries and placing care delivery around the patient can only be achieved with digital solutions.
I would like to provide the committee with an overview of the current resources available to the HSE to take forward this digital agenda. We have a very lean team in comparison to other Government Departments and health care systems. There is one IT person supporting every 236 people in the HSE today. Other Departments such as the Revenue Commissioners have one IT person supporting every 11 resources. In other areas, such as social welfare and agriculture, there is one IT person for every 17 resources to support their complex agendas.
The current average EU health care budget spend on digital solutions is just over 3%. The HSE has around 1% of its budget allocated to this agenda. In 2016, we secured permission to add further resources to the team, around 49 new people. This has been progressing through the year as we start to bring those people on board and into the team.
The HSE has created a function that can work in an agile manner. It does not require funding linked to EU norms. However, it will necessitate a steady programme of investment that, over time, enables it to become a function that drives business change and supports digital delivery in health. I ask the committee to give consideration to how digital solutions can be implemented in health care over the next decade. In order to truly realise benefits, the system needs to be equipped with business change capabilities and the ability to apply funding from IT to business change.
Clinical leadership of digital projects today is the key enabler of the of the work eHealth Ireland is doing. More than 200 clinicians across 45 disciplines now have the additional role of clinical information officer. This resource is there to ensure that projects that used to be focused on the delivery of IT are now there to focus on the delivery of patient and clinical benefit. The vision can overcome many operational issues in the creation of integrated care. Digital is the catalyst for the delivery of an empowered patient who expects and rightly assumes that care is integrated.
In 2015, the Minister's office asked us to consider how we could learn through real Irish digital projects within our current budget. We chose three radically different chronic disease areas to focus on: epilepsy, bipolar disorder and haemophilia. These areas became known as lighthouse projects. Haemophilia now has a patient solution that allows illness to be managed, controlled and audited digitally. The supply chain of that treatment can now be managed at home with the patient's mobile phone. The solution also allows patients to have access to their records and will this year enable secure communication with their clinicians. The Irish Haemophilia Society has considered the savings in this programme and puts the figure at around €10 million a year in drug cost savings.
A second lighthouse project is epilepsy. Ireland has begun its first genomics sequencing programme in partnership with the Royal College of Surgeons in Ireland. Through seeking for the genome of suspected epilepsy patients we can provide efficient and safe care to a cohort of patients; fatalities could be avoided and the cost of treatment has come down dramatically. There are as many as 130 epilepsy-related deaths in Ireland each year, 90 of which are considered to be undiagnosed children. The cost of finding the correct medicines for those patients is approximately €5 million year. Investment in this project has made and can continue to make treatment available for 40,000 epilepsy sufferers in Ireland. Treatment can now be personalised and contextualised to their type of epilepsy.
The final lighthouse project is in the area of bipolar disorder, which affects 1% of the Irish population. The ability to treat complex mental health issues through the use of digital solutions is yet to be fully explored globally. Ireland has been able to invest and we consider bipolar disorder as an area to concentrate on. Delivering a solution for the recording and communicating of the patient's disorder directly to the clinician is the first step for this calendar year.
I would like to describe a number of national solutions that have been the focus of our attention over 2016. These are projects that can become the foundational elements of the future of a digital fabric of Ireland. In the coming weeks, the individual health identifier will be connected to the first local health system, joining up information and supporting integrated care. The technology infrastructure to support the individual health identifier, which was legislated for in 2014 by the Health Identifiers Act, is now live. The complete population and building of the process to support this within health are under way. The Department of Health continues to work with the Department of Social Protection to get agreement on the linkage between datasets, all of which is made clear in legislation. This will allow us to populate many of our current and new information systems with the IHI, ensuring that patient information across a range of systems can be safely connected. The HSE is ready to place the individual health identifier on all electronic referrals as soon as the Department has completed this negotiation.
The implementation of electronic referrals in every hospital in Ireland is now complete. More than 40% of GPs used the service in August 2016, with 10,733 referrals being handled by this digital service during that month. This means that a patient can see the arrival of his or her referral in the hospital while he or she still with his or her GP. This solution removes the need for a paper referral and for the GP practice to post the referral, where the referral can touch an estimated 11 hands in its movement through the health system. This digital process enables an increase in efficiency, security and traceability, and allows us a significant opportunity to modernise the referral process. This will clearly have an impact on waiting lists across the system and will create a significant cost reduction with the removal of paper referrals. The referral project is now moving to the next stage, with the ability for patients to see their referrals digitally and to make changes to the time and date of their appointments. Due to the success of e-referral, we can now move to consider how e-pharmacy and electronic prescribing can also be added, and a focus will be applied to that in the coming months.
There are three other key projects that are a priority to the end of 2016 and that will begin to deliver benefits before the end of this year. The first national digital health record solution will be the maternity and newborn clinical management system, MNCMS. This will be deployed in Ireland's maternity hospitals over the next 18 months. The first hospital will be Cork, in late October, and Kerry, in late November this year. Moving one of Europe's busiest maternity hospitals from a largely paper-based administrative system to one which is almost paper-free and supports clinical practice is a major task, but one that is on track and is clinically led. Delivery in this area will allow Ireland's maternity services to ensure national integrated care is safely and efficiently delivered into the next decade.
Ireland will move to a single digital lab system, known as MedLIS. This will allow information to be shared securely across the areas of care that have a legitimate reason to access this type of information. Electronic ordering, tests and results and sharing between acute, primary and community care settings will reduce the burden of testing and retesting. This will have a significant financial saving as well as being more convenient and, in some cases, safer for the patient.
Another priority is the connectivity of delivery staff to digital solutions. The connection of the 47,000 health staff who today have no access to any digital solution for their work is a key enabler for eHealth Ireland to put in place. The priority areas include the implementation of 10,000 new physical devices into community and primary care, areas that are currently largely paper-based. This is crucial to the success of all digital projects.
Ireland is the first EU member state to avail of the Health Cloud First policy. This technical term simply means that the clinical resources of Ireland can access their system safely, securely and from anywhere. They can do this happy in the knowledge that information remains within Ireland and is protected to a high globally recognised standard. One of the next areas that can avail of this is the cancer care solution, known as MOCIS. Currently, cancer care is delivered largely on paper and does not have a digital solution to support it. Early in 2017, MOCIS will also begin its journey to go live.
Before closing, I would like to speak about the opportunities of the future. I hope what has been made clear today is the opportunity of the present, the building blocks that are being put in place and structures set up to facilitate the ten-year journey ahead of us. The concept of an electronic health record Ireland is not new. However, Ireland now has a well-structured and HSE-approved route to deliver an electronic health record.
This programme of work will span ten years and will put in place a set of solutions built around the individual health identifier, which will be deployed in a modular fashion to the benefit of the whole health care system. It is in this area that Ireland can come to the concept of digitally connected health care systems and leapfrog other jurisdictions. The concept of an electronic health record described in the business case is not one of a single, monolithic Irish Government database, but rather involves connectivity, integration and transformation and clinically led implementation with the person at the centre. This is a ten-year journey that the electronic health record programme will put in place. It is not an immediate large investment, but rather a commitment to incrementally evaluate the success of digital over a ten-year period and continue to add to the investment as benefits can be seen and success is clear.
It is crucial for Ireland that this solution is not a big bang but an evolution of today's systems, set in stone as we move to 2020. By 2020, clinicians will be able to access digital information about patients appropriately, and by 2025 we will see a digital fabric throughout the health system including a system that is also accessible and in the hands of the people of Ireland. It is important to reiterate this is not a single one year investment; it is a continuously assessed multi-year investment over the lifetime of the programme.
I thank committee members for their attention and interest in these key areas. The success of the past 18 months can be built upon with support, investment and enthusiasm. We believe we can truly change the way in which the health system can work together by enabling eHealth Ireland as a digital catalyst. I and my colleague will endeavour to answer any questions committee members may have.
I thank Mr. Corbridge for his presentation. He referred to the evolution, which is particularly slow. It is hard for many of us to understand why the evolution has been so slow. We have been speaking about an individual health identifier for many years. It was legislated for, as Mr. Corbridge stated, in 2014. What is the difficulty with the Department of Social Protection? Why are we still in a situation where the HSE is trying to negotiate on data sharing?
My next question relates to the urgent need to ensure electronic referrals and record-keeping at primary care level in particular. Mr. Corbridge stated 40% of GPs use electronic referrals This is very low in this day and age. What needs to happen to increase this figure to 100%? Mr. Corbridge referred to the fact that 47,000 health staff have no access to any digital solution. This is quite a shocking figure in this day and age, when the vast majority of workers and teenagers have access to digital solutions for whatever work they are doing. Why is this number so large? What needs to happen to expedite this to ensure standards are increased to an acceptable modern level in the HSE?
Mr. Richard Corbridge:
I will answer all of the questions and Ms Goff may add clinical patient focus. The negotiations between the Department of Social Protection and the Department of Health on the use of PPS numbers and sharing information have reached the point where there is a memorandum of understanding between the two Departments. Once this is finalised and agreed we can begin to use the individual health identifier. The length of time between the Act and going live is, to some degree, to do with investment and being able to work out how to begin the implementation. We started the technology part of this 18 months ago. To do this in 18 months is considered by other jurisdictions as quite a significant achievement. It has taken a long time to work from the Act to understand how to implement what we have done, but the solution has been put in place in 18 months and brings about a great change.
Ms Yvonne Goff:
I could not agree more with the Chairman. From a clinical point of view, it is absolutely essential. It is key to bringing patient data together. All of the national systems we have been implementing for the past 18 months, or five years, have been built based on being able to take the additional individual health identifier number. We are ready to go.
Mr. Richard Corbridge:
We began implementation of electronic referral with major project investment 12 months ago. To move in 12 months from three hospitals in Cork and Kerry to every hospital in Ireland being capable of receiving an electronic referral is rapid progress. GP systems in Ireland are already predominantly digital and the electronic referral solution is being built in such a way as to allow GPs to have access to it. The biggest selling point, for want of a better way of putting it, of electronic referral for a GP is the removal of cost. A GP would no longer need to complete the administrative functions of printing, putting a stamp on an envelope and sending it. We have seen a very quick take-up of the electronic referral service. The HSE has set itself a target of having 100% of GPs using the electronic referral service by 1 April next year. This will be a joint leap forward because it will give patients access to electronic referral and will allow us to collect information and use it in an anonymised way to manage the referral process and patterns.
Mr. Richard Corbridge:
Creating an electronic health record for Ireland is a much bigger and wider programme of work. The e-referral will start to build a foundation to get people used to using digital solutions. The reality today is many of our hospitals and healthcare systems are almost entirely reliant on paper. E-referral is one of a number of projects to create a foundation to allow us to build on it and start to move forward.
Mr. Richard Corbridge:
It is a shocking to think about this. As the Chairman rightly pointed out, we probably all have a very powerful pocket computer today, and the HSE has not had the funding to implement this type of digital fabric into the healthcare system. In April, we set ourselves a target to connect these 47,000 people to digital solutions. This means giving them the ability to log onto a computer that will be in their care setting. It gives them the ability to have an e-mail account and solutions they can start to use to do this. What is perhaps even more worrying are the 10,000 people in primary and community care who have no devices and our programme to roll out these is well under way. In 2015, Ireland was the largest EU population to roll out new Microsoft solutions into what we deliver and we followed up on this commitment this year.
I thank the witnesses for coming before the committee. I understand the IT spend in 2009 was approximately 0.75% of the budget. By international standards, what is required to meet the targets and be on track? As has been stated by my colleagues, we are behind on this. The HSE is putting in place very good targets but what is required percentage wise when we consider what other countries spend on investing in our IT systems? Mr. Corbridge stated e-prescriptions are coming down the track in the coming months and I ask him to expand on this. With regard to the GP uptake of 40%, what has been the main barrier to date with regard to the slow uptake of e-referrals? Is the HSE leveraging the skills and experience of the ICT industry in progressing this to help it meet its targets and develop the IT systems?
Deputy Naughton mentioned electronic prescriptions and I am very interested to hear more about where we are with this. Reference is often made to a push pull system with prescriptions. Where are we with regard to patient choice in Ireland? A family member is a pharmacist in the Netherlands and in that country a defined number of patients are directed to a particular community pharmacy setting so an element of choice is removed. As a community pharmacist, I am quite interested hear where we are with this. With regard to the Department of Social Protection, recently I received an identifier card with a chip. A chip seems outdated at this stage. If we are to integrate systems, is it true to say the card will be defunct?
If there is to be one number identifier per patient, it seems somewhat bizarre that the social protection card would not be used. Why not simply have one card for everything? As for spending in this regard, I may have missed this at the outset but technology moves so quickly that when something like this is being done over the next ten years, is the ability to adapt to changes that happen in the technological world being factored in? It is great to see the savings in these few projects. Perhaps I am missing it but does the Health Service Executive, HSE, have data showing the savings made when this is done whereby, for example, if one invests €10 million, one will save €20 million over ten years or whatever? Are such data available because significant amounts appeared to have been saved already?
I thank Mr. Corbridge for the presentation and while I apologise for missing some of it, I got a chance to read it beforehand. In respect of the 47,000 people who currently do not have access to a computer as part of their work within the health service, I assume that number does not also take into account agency staff who are not directly employed or does it? Second, this is more of an observation than a question, as someone who has represented workers in the health service, but there is great emphasis on making sure those who are senior management in the health service have access to a wide range of equipment. They have iPads, iPhones, BlackBerry devices and everything else but those who are on the front line and who might benefit most from it do not. For example, when the health service introduced electronic payslips, none of the catering staff in hospitals were able to access them and likewise for directly employed cleaning staff, health care assistants and people like that. However, senior managers who would not necessarily have a need for all the information and communications technology, ICT, equipment because they have desk computers, also had all the mobile information technology, IT, equipment to go with it. There must be something of a refocusing on who actually needs the technology.
The 2017 figure for capital investment in ICT is €55 million. In Mr. Corbridge's estimation, will that come close or will it even knock the corners off it? Deputy Naughton alluded to a percentage of overall expenditure on health but rather than a percentage, what actual capital figure does Mr. Corbridge perceive to be necessary to ensure some of the fairly ambitious targets he has outlined can be hit? Finally, a system of integrated waiting lists is in operation in Portugal at present that all the figures suggest has had a significant impact on reducing waiting times. The system has integrated all of the waiting lists rather than having separate waiting lists. In Mr. Corbridge's opinion, were this to be done would there be a saving to the Exchequer? How far is the HSE from being able to introduce a measure that is fairly desirable and that makes a lot of sense? How far is the HSE from having such an integrated waiting list system or is it dependent on the unique patient identifier, which unfortunately and regrettably is taking a long time to implement?
Mr. Richard Corbridge:
I thank the Chairman. First, on funding and the size of funding, the team size, that is, the people on the team probably is the area we must consider most in 2017. We are spending money from a capital point of view that allows us to buy technology. Our biggest problem is having people to implement and, in particular, with people working with Ms Yvonne Goff's team to do the business change part of it. It is all well and good to have enough money to buy the brown boxes and cables and to put them into hospitals but we need additional resources to train people and make the business change happen. There is a real risk in information technology across the world and in health care in particular of spending money on technology that people cannot use. This is a major pattern that was seen in the United States and is why we have concentrated in 2015 and 2016 in particular on making sure that the clinical engagement, namely, the 200 people working with Ms Goff, bring to bear that resource, which is different, on how we actually implement in that space. My suggestion or request would be that consideration be given less to the capital budget and changes therein and more to the revenue side. IT in general is moving more towards a platform as a service, that is, things as a service one buys each year, rather than as an investment that lasts for five or ten years. One point to bear in mind with technology and the investment thus far is that in Ireland today, there are patient administration systems in hospitals in Dublin that are 32 years old. That kind of investment has not happened and therefore driving that forward would be a useful way to go. Would Ms Goff like to say anything about the ePharmacy piece?
Ms Yvonne Goff:
The ePharmacy programme has just begun. We are considering three pillars, the first of which is the national drug catalogue. The second is e-prescribing in the community and a third concerns pharmacy within the hospitals. Of the group of 200 clinicians, 19 are pharmacists and another subgroup comprises doctors who are interested in pharmacy. They have come together and are considering a solution that would address everyone's needs. For instance, Deputy O’Connell asked a question about patient choice. In England, as she is aware, they started with no patient choice and a patient was obliged to go to a certain pharmacy but they now are in a different phase in which they are broadening out the patient choice. Again, to revert to the point made earlier by Mr. Richard Corbridge, although we are slow to the game, we have the benefit of learning from other countries and will continue to so do. We definitely do not have all the solutions with regard to the ePharmacy programme. It is at the beginning and it is being scoped out at present.
Mr. Richard Corbridge:
Another question concerned general practitioner, GP, uptake of the referral solution. As for the suggestion that it has been slow, it has been 12 months and as of August, 40% of GPs are now using it. That is not actually really slow for health care and technology. Health care globally and not just in Ireland takes time to adopt digital solutions. In respect of what we actively are doing, over the next month we will begin a communications process with the people of Ireland, namely, the patients. We will tell them that the next time they are in front of their GP, they should ask to be electronically referred. The benefit to a patient in how they feel when they have been electronically referred, rather than handed a referral and asked to post it or get to the hospital themselves, is significant. Increasingly, patients asking their GPs is what will drive the process, particularly because thus far, GPs have been warm to the electronic referral because it reduces their costs and brings efficiencies. Our commitment is that within 12 months, we will be very close to 100% of first referrals out of GP practice being electronic referrals, which globally would be quite a quick implementation of a solution like that.
Ms Yvonne Goff:
Part of that is a cultural change as, for instance, we carried out the same process with radiology reporting. That was going out through Healthlink, which is the same process as we have for the referrals. As GPs were not comfortable with not receiving a paper report for a long time, we spent significant time on a communication plan and building up to a time when we ceased printing reports and over six months, there was a saving of €150,000 based on that. It was through communication and working with the GPs in particular that they became comfortable with moving into this environment.
Mr. Richard Corbridge:
Deputy O’Connell mentioned the HSE engaging with the ICT industry and she is quite correct in that right across Dublin and Ireland, we see many partners that could help us. The HSE has created something called the eHealth Ireland Ecosystem. That is a group of people, now 300 in number, who come together each quarter to help eHealth Ireland drive forward its agenda. They range from some of the biggest digital organisations globally, which come and provide assistance - not at cost - to make sure we can learn from other jurisdictions and keep driving forward in how we do this. The ecosystem was set out in the original eHealth Ireland strategy as something that should exist and 12 months later, with such numbers of people involved, it has been highly successful. We use a lot of the digital organisations not as contractor partners, but as organisations that are willing to provide advice and guidance on where we go. This has been particularly useful in the past six months as we have started to learn more and more about different jurisdictions as we have built the electronic health record business case.
The Deputy also mentioned the public service card. One plan through which the Department of Health is working with the Department of Social Protection is on how the individual health identifier can be on that same card, that is, how in the future that number and code could be part of that same identity and dataset. It is a discussion between the Department of Health and the Department of Social Protection about how to make that happen. It makes complete logical sense to do it; the Deputy is absolutely right to say that. As for the speed of technology adoption - this is something on which Ms Yvonne Goff can also comment - I have worked in health care technology for 20 years. I have never seen such amazing clinical engagement as that which we have in Ireland. Clinicians in Ireland want technology and there are two key reasons for this. First, the system in Ireland is largely paper-based and clinicians can see that this perhaps is not always the easiest, most efficient and safe way of delivering health care. Second, many clinicians will have worked in other jurisdictions that have digital solutions. Consequently, our pace is very much based on the business change capability we have put in place. We must not do what the United States has done, where digital is done to clinicians and clinicians walk away from digital and stop using it.
Ms Yvonne Goff:
Quite simply, clinicians are involved in all the programmes we are developing from the point of procurement all the way through to support. We are less likely to buy a system that will not fit into meeting our needs or will never fit into doing so. That is the way we work together with our IT staff on every one of our technology programmes.
Mr. Richard Corbridge:
Deputy O'Connell mentioned savings and efficiencies. The electronic health record business case, which the HSE, eHealth Ireland Committee and the Chief Clinical Information Officers Council has approved, is now with the Department of Health. It stresses the efficiencies and safety savings that can be made through implementing an electronic health record system. It does not give a literal figure for each hospital, community setting and mental health setting. That has been proven in the NHS in particular to be quite a dangerous thing to do. What it can do is make sure the system becomes more efficient and more safely delivered, and that is crucial to that business case and how we take that further forward.
The 47,000 people Deputy Louise O'Reilly referred to in our document also includes agency staff. It is the people who work in the health care system. A process will be put in place to enable a single digital identity for a member of staff who is working in the health system regardless of where they work across the health care system. The Deputy's comment on the level of technology is spot on. It is very much the case that we consider how we can use technology at a more senior level rather than its implementation at the front end. Ms Goff's team drives us to make sure that is not what we do. That is unique for Ireland. In other jurisdictions in which I have worked, the clinicians have said they want and need this technology rather than it being a management function illustrating the technology that could be in place.
Mr. Richard Corbridge:
Deputy O'Reilly mentioned figures and asked what additional money we would need. The electronic health record business case considers a capital investment of around €107 million in year one. That is not an insignificant additional amount of capital but I would refer to my earlier comment about revenue and about the ability to have the right number of people employed by the health system to implement this. We need to be careful not to rely on temporary staff, contractors and consultancy teams and to make sure that we lodge the intelligence and capability to deliver this in the Irish health care system and not be reliant on temporary resources.
Mr. Richard Corbridge:
It is. Slide 10 details the revenue costs, the capital costs and the spread of resource over the year. Slide 10 in the document pack we have provided gives members the details on that.
The last question was about integrated waiting lists and the possibilities around that. Many members will be aware that in the past three weeks we were asked by the Minister to deliver a digital challenge solution to the waiting list issue that exists today. That is now with the Minister's office to consider how that could be put in place. That includes a 12-month challenge and an additional spend of €1 million, and one of the products within it would be an integrated waiting list. In terms of electronic referral system, when moving referrals to an electronic solution, it is not that difficult to create an integrated waiting list from that solution.
Mr. Richard Corbridge:
In the NHS the national programme for IT was alleged to have spent £13 billion sterling on technology and that was against a physical saving that the national programme for IT suggested it would make. We forget sometimes that the health care systems of the world are based on demand. If we make a system more efficient, it does not remove demand. It just means we can do more. Therefore, to say one would save money is not something that I believe a digital solution would do in the health system. It means that one can provide more care, be more efficient and deliver what one does more safely rather than return money to the system.
I thank Mr. Corbridge for his presentation. Most of the questions I had have been answered. They related to the 47,000 staff, the 10,000-plus devices and the issue of data sharing. Is there a definitive report or has anything issued yet on the pilot scheme for Cork and Kerry, or is it still in its infancy? Can we get data on that?
I apologise if this question has been answered as I had to step out briefly. How big an issue is data protection for the future of IT or ehealth care? If there are issues, do we need to legislate to overcome them? I would hate to think that we would continue run up against a problem because of data protection. Sometimes we have to serve the greater good. I would be interested to get our guests' views on that.
It is stated in the summary that this is a ten-year journey and that it is important not to have big bang solution - I think that was the phrase used. Given where we are at with IT and, as Deputy O'Connell pointed out, it changes almost annually in that what we are using today is almost obsolete in 12 months' time, should we be more ambitious? It was stated that this is a lean, mean operation, but are we fit for purpose? Revenue is pretty efficient at what it does, too efficient perhaps for people like me if I were still in business. Is, as was mentioned, one person per 11 what is needed, and if it is, is that what we should be striving towards? As a committee we have been set up to come up with a ten-year strategy. Mr. Corbridge spoke about a ten-year strategy, so there is a sort of fit there. I have seen the benefits of improvements in ehealth for local GPs who work with the system through the hospitals, and the amount of time and energy saved by the exchanging of information electronically is colossal. Are we ambitious enough in this area?
Most of the questions I had have been put forward. I am very interested in this paper and presentation. The witnesses have an incredibly difficult job. In a previous life I used to manage large integration IT projects, so I can share their pain at times. Much of the pain is not due to IT. Sometimes it relates to the decision-making and the process. Leaders are very important in projects that are going to take this length of time to implement. Historically, if we consider many of the integration projects that have been done in this country, and they are very well known from the media given the volume of funding that has been put into them, there has been a loss of critical leadership at certain points. Effectively, many of the people, including the witnesses at the top of tree, are single points of possible failure.
Is there a process for managing that, particularly as people move on all the time?
The second issue is technology use. Deputy Brassil stated that everything moves and that changes take place every year. That is the case. It changes every month at this stage. Obviously, from an IP point of view, I presume open source is being managed in a way that allows continuity rather than technological single points of failure. I presume there is a methodology for doing that and we do not get locked in with any supplier to the point where we cannot get out. I remember being involved in the launch of the Leap Card in respect of which there was a process whereby technology partners were locked in and it caused significant delays.
I am a huge supporter of the public service card. That is a massive project. At what stage is the HSE in its conversation with the Departments of Public Expenditure and Reform and Social Protection, both of which are involved with that project? I presume it is on a continuous basis and Mr. Corbridge might let us know whether that is the position.
I am delighted to hear about eHealth Ireland. I knew a little about it but not enough. How does Mr. Corbridge find stakeholder engagement in this regard and is everyone covered? From a buy-in point of view, this is a necessity not only among technology partners but across government?
I will not begin to discuss medical devices because a lengthy conversation is required in that regard. The IT projects that are being done within the Department of Health and the data management system are integrated but they also separate. We spoke earlier with Dr. Stephen Kinsella, who made a good presentation. There is an overlap in respect of some of the aspects here. I refer to consistency in data, the processes for managing data and the back-end database. The quality of data is essential. As stated earlier, there is a phrase which goes "dumb data in, dumb data out". In the context of the process for managing data - the differential regarding the management of it from the top down - the IT aspect is one issue. Obviously, it is ever-changing. However, it is about ensuring that there are standards as regards data input because all the technology in the world is irrelevant if the data are not being input correctly. I accept that they must come together but I presume they are managed throughout the network down to the very lowest level separately. Those are my questions.
Mr. Richard Corbridge:
First, the Cork and Kerry maternity hospitals, that is, the area we were looking at, they are not pilot projects. They are the first sites that will go live. Obviously, we will evaluate each site as it goes live. They are the first two maternity hospitals to go live. The clinical engagement and passion in both hospitals for that system to go live successfully is phenomenal. The solution that is being deployed is an American solution that was procured a number of years ago but has been clinically built and validated specifically for the delivery of maternity care in Ireland. I personally have never seen a more committed clinical team to make a solution go live well. There have been 8,000 man hours of training in Cork hospital alone to ensure that system goes live successfully over the weekend in October, and then the team moves on to Kerry. We in the team all are personally committed to ensure those two sites go live well. New IT systems, particularly those in the area of health, will often give rise to issues when they first go live. We know how to manage those issues in Cork and Kerry and have a good team on the ground to ensure they are fully supportive. We strongly believe that they will not be pilot projects; they will be proving how this should be done for hospitals across the rest of the country. The programme team is ready to roll that into every one of the maternity hospitals. Ms Goff may want to say something about the clinical engagement aspect.
Ms Yvonne Goff:
It ties in to the second question about the big-bang solution. One of the restrictions is that we have our solution and we have huge clinical engagement, but it is difficult, from a clinical point of view, to keep the business running as usual. Midwives and doctors have to be released to test and train on these systems and although we might be asking for a large number of IT staff, we also need the clinicians to be able to attend that training and to build and test that system as well. It goes to our big-bang theory a little bit that, unfortunately, we are not at that stage and we do not have an unlimited number of clinicians at present.
Mr. Richard Corbridge:
Moving to the savings in individual hospitals, where we take a national solution, such as the health cloud first solution, which will release money that is spent locally. This means that money can then be spent in those local hospitals and on mental health and community organisations. Where we have deployed solutions such as the electronic referral into GP practices, that saves money in such practices. However, that money is not pulled back to the centre. It is money that is released in the GP practice to be spent differently on particular efficiencies. The same goes for simple solutions, such as mobile phone bills. There is a single mobile bill solution for the HSE that has saved millions of euro. However, those savings are not re-spent in the area of technology. It is important to point out that they are re-spent across the HSE.
Mr. Richard Corbridge:
On the question regarding data protection and legislation relating to it, other jurisdictions have ultimately failed to deliver technology into health for multiple years because they have fallen down in the context of data protection. We go into this with our eyes wide open and having learned those lessons. One of the principles we have adopted, particularly in terms of the electronic health record, is that data protection and the ability to govern who has looked at information to do with health will be placed in the hands of the patient. We will enable a patient to log-on to see who, from a clinical point of view, has looked at his or her records and be able to do something about that. That has been proven, particularly in Estonia, as a way of taking away many of the concerns around data protection. The concept of a legitimate relationship to access information, I personally believe, is something in respect of which there is a need to change legislation in order that it might be contemplated. We must also consider how we do that so that we have health information legislation around accessing health information is important to the success of our programme. We have seen, even in the past six months, issues in the NHS where large programmes, after quite a significant spend, have been stopped because of data protection concerns. We work with the Department of Health to ensure that we address our data protections and keep striving to deliver in that space. Something called the privacy impact assessment was completely around the individual health identifier before that was made capable and live. That was done in the public domain, with comments from the public, to try to ensure that we bring people on the same journey that we ourselves are on in that space.
As Ms Goff said in respect of the big-bang solution, the ten-year strategy and the ambition we have in that space, our rate-limiting factor on the delivery of technology in Ireland is probably not technologist, it actually relates to clinical capacity. The Cork hospital example is a prime one, where 8,000 hours of training were needed in a hospital before a system could go live. That cannot be fulfilled by putting IT staff into that place. Business change is what drives efficiency and benefits from digital, and business change cannot be done to people. It is clinical time that is most needed as opposed to IT staff. That is one of the asks in the opening statement - to consider how, at some point, the digital health budget could also include capacity to do business change. Currently, my budget does not allow me to spend money on business change. It only allows me to spend money on technology. I must then seek assistance from the system itself to spend its own clinical budget on business change and that makes it somewhat challenging sometimes to ensure that business change can happen.
On the question around leadership and how to keep it in place, we have built a strong team across eHealth Ireland. Throughout the whole function, as small as it is, we have a team of passionate people who believe strongly in what they are trying to deliver. There is the ability to move that team and flex it to reflect the Health Service Executive itself and how we change our structures and what we deliver. Having 200 clinicians and a chief clinical information officer who is considered to be the deputy CIO is hugely important to me personally because that means that we are clinically led and have clinicians involved in where we are going. We are striving to ensure we combat any issues around changes in leadership, changes in styles and changes in structures. We have created a national structure in the past 18 months. Previously, we had lots of local IT teams. That also has been crucial in ensuring that we deliver a single vision for where we go.
Ms Yvonne Goff:
I want to point out on all of our projects, because Deputy Kelly mentioned single point of failure, on each of our teams we have a national team and a local team so that there is also bi-directional communication the whole time. We are trying to ensure there is not a single point of failure.
Mr. Richard Corbridge:
Deputy Kelly also mentioned the concept of how to manage different solutions. In the context of the solutions we have deployed thus far, we have made clear that we will not accept a single solution. What we are looking for across Ireland - if it was possible to go back one slide in the presentation then there would be slide that would demonstrate this - is not a single system or solution. It is actually about being able to have a set of solutions that come together to deliver that integrated electronic health record. It has been important to learn from the experience in other countries in order to ensure that we can drive forward how we deliver those different solutions and put them in place.
That is a really big part of it.
The Deputy mentioned the public services card. There are very early negotiations around the individual health identifier and health information could become part of that public services card. That is very much a discussion between the Department of Health, the Department of Social Protection and the Department of Public Expenditure and Reform. I have been working very closely with the Government CIO to make sure the health information that could be part of that card can be driven forward and moved into that space as closely as possible.
Mr. Richard Corbridge:
The Deputy mentioned stakeholder engagement and buy-in from eHealth Ireland. We have phenomenal engagement from a clinical point of view out into our hospitals, community settings and GP user groups. Probably the biggest part of the role today is trying to make sure that engagement is there. We are trying to ensure that people understand the eHealth Ireland journey and the direction of travel. One of the ways we have done this is by trying to pick projects that we can deliver each year, as well as the end goal. Projects like epilepsy genomic sequencing, the bipolar project and those lighthouse projects were picked very much to invest time, effort, money and communications in order to engage different cohorts of people in how we can drive benefit to different patients. The success has been phenomenal, and we would in particular call out the epilepsy area. We believe Ireland is the first country in the world to start a genomic sequencing programme for epilepsy so that, by sequencing the genome of a child under the age of five, one can find out what is the right drug for that child. There is no need to try lots of different drugs and we will no longer have 90 children under the age of five dying. It is a huge programme of benefit and one that other countries can and will be able to learn from.
Mr. Richard Corbridge:
The last question was around the separation of IT and data. What we have put in place over the past 18 months is what we call the eHealth Ireland design authority. This will be a function that has the final say on solutions that are deployed throughout the system to make sure the data models integrate and interact across the whole Irish health care system. We have a data dictionary in place which captures all of the single data models and allows different systems to reference that. We have put a lot of effort and work into trying to make sure our single data model can move forward.
I thank Mr. Corbridge and Ms Goff for very interesting documentation and their presentation. I have two questions. One relates to the issue of electronic referrals from GPs and the other relates to the savings identified by the lighthouse projects. With regard to the electronic referrals by GPs, perhaps I got the information wrong, in which case the witnesses might correct me, but my understanding is the programme has been rolled out over the past 12 months and there is a 40% take-up. The witnesses are predicting that by April of next year we will have reached the target of 100%. I hope they are right but I want to ask what are the grounds for their confidence. If it has gone from zero to 40% in that period, unless there is an increased take-up, we are looking at a percentage in the low 60s by April of next year. I would imagine that, in a situation like this, there would probably be one third of GP practices that would take to it like a duck to water and buy in fairly quickly. Once they were on board, however, it would begin to get tougher and, in the normal scheme of things, one would expect it to slow down somewhat. There is also the age profile of GPs. It is not the laptop generation. I can think of GPs who I would imagine will be slow to move from paper to electronic referral. My own doctor has an electronic referral system but that is not the case with other GPs I know. On what is the idea based that we will be at 100% by April of next year?
The savings identified by the lighthouse projects are €5 million next year on epilepsy and €20 million over three years on the haemophilia sector. I would like to hear a breakdown, not to the nearest euro but in broad percentage terms, as to where those savings are coming from. I have listened to various points in the presentation and during the questions, so I can see mobile phones are one area for savings, given a lot of money was previously spent on phone calls. There will be savings on drugs, as was indicated in regard to the genomic sequencing for epilepsy. Is that part of the savings that are identified here? What about labour costs? I can imagine there will be a need for fewer people to do the work once the IT systems are in place but surely that would not be a saving to the health service in the sense that people are not being made redundant and they would be transferred to other work. Is the HSE counting the fact they are working in other sectors as part of the savings? How do the savings break down?
I thank the witnesses for their presentations. A lot has been asked and answered. To bring it back to the practicalities of the delivery of health care in general, if we look at the various policies that have been outlined by the Department of Health, the HSE and various Governments, and probably by this committee in its final deliberations, without setting that it stone, primary care and community care will be where most health services are delivered in the years ahead. This will be for many reasons, in particular cost efficiency, but it is also the obvious place to deliver health care as opposed to acute hospital settings.
To put it into a practical example, a public health nurse calls out to a patient in some part of the country, he or she makes an assessment of the patient and, given he or she may or may not be prescribing nurse, it may be necessary to refer back to the GP to prescribe. The GP should then, in theory, be able to prescribe through electronic means to the pharmacy, and all of that should be centralised under the individual health identifier code. The question is how far we are away from this happening. I visited a GP practice recently where the staff have to put the mobile phones into a car and drive to the top of a hill to download messages before driving back to the surgery. That is happening as we speak in rural parts of this country. While we are trying to move to this model, do we have the infrastructure in place and has this been considered in terms of the ability to roll out e-health across the country?
To follow on from a question asked by Deputy Barry, there is the issue of the support and training that would be required. While come clinicians are technologically advanced and want to embrace technology, others may be resistant or may not feel confident in engaging in that process. The witnesses mentioned a figure of 40%. In general, it is those who are interested who will step up to the plate first and it then gets harder and harder to encourage or, possibly, force people. In that context, how much is being put aside in the HSE budget for training and support in moving people to e-health?
Reference was made to 47,000 new digital identities and 10,000 staff being given access to a digital device by December 2016. Is that digital device an iPad or a tablet? What type of device will they have access to? With the continuous advances in technology, how flexible will contracts and tendering processes be in terms of ensuring we are not burdened with out-of-date equipment, given tendering processes can be very slow in this State?
How compatible will our system be with other jurisdictions? For example, there is an EU directive whereby people can access treatment abroad if it is not provided for in this State. This is one area where I wonder whether information can be transferred electronically to clinicians in other jurisdictions who are taking on an Irish patient.
On the issue of collating data, the Scottish did a lot of analysis of prescribing by individual GPs and GP practices. Would e-health make that more efficient or do we already have systems in place to do that?
Mr. Richard Corbridge:
On the question of e-referrals and how we get to 100%, it took us until May of this year to get all hospitals enabled to receive electronic referrals. Over the year that we have moved from 0% to 40% of GPs, we have moved from no hospitals to all hospitals being able to receive an electronic referral. Obviously the rate limiting factor in being able to send an electronic referral is that the hospital needs to be able to receive it at the other end. The Deputy's point is absolutely valid that there are practices out there that are not digital today, but it is only around 3% of practices. The electronic referral solution that has been deployed is agnostic of the GP system that is already deployed. It is a web-based solution that GPs can access easily. It has been built to make the process as simple as possible and to illustrate the efficiencies and savings to the GP practice of using it. The target we have set ourselves, not just in new referrals but in a number of places, are stretch targets. We are setting these targets to allow the team to have room to stretch and believe it in terms of where we can get to with e-referrals and other subjects. That is why we have said 100% of practices by April of next year delivering electronic referrals. That is direction we are taking in that space.
The issue of savings, specifically with regard to epilepsy and haemophilia, was raised. The savings relating to epilepsy that were called out at around €5 million are based on the fact that if we could sequence the genome of everybody with suspected epilepsy, we would know the type of drug with which to treat them. Last year we spent €5 million on drugs while trying to find out which was the right one for treating patients with suspected epilepsy. That is where the €5 million in savings comes from. If we spend money on sequencing the genome, we know the right drug to use straight away and, therefore, we save that €5 million. The money that was suggested around haemophilia arises from savings around the supply chain management. If we do not have a supply chain solution that is deployed to the patient then we do not know whether the patient has received all of the treatment he or she needs or whether the patient has had a bleed. Therefore, we are constantly sending the treatment to their fridge in order that they have it on board. The Irish Haemophilia Society did some work in the past two years to try to understand how an early version of that solution was saving money and that is where those figures came from. They are very specifically savings related to drug wastage, with drugs being stockpiled in patients' homes, as opposed to any of the other additional savings that are in that space.
Reference was made to primary and community care and how we get GPs involved and move it forward. Our work with the GP systems suppliers of Ireland, of which there are two main players, has been forthcoming in terms of how they adopt the individual health identifier, IHI, and put the electronic referral and e-pharmacy solutions into their systems. We believe the relationship is in a good place with those systems and with those people and will drive forward a change in that marketplace. The fact that Ireland only has two organisations to engage with to drive forward changes in those systems is phenomenally useful for us because we can build relationships and standards and have the design authority to put those systems in place. It enables us to drive forward how we extend the functionality that is available in GP systems out into the community.
One of the four pillars of the electronic health record, EHR, is to deliver EHR functionality into the community. We believe community is an easier place than an acute hospital to deploy the EHR because currently there is no digital solution there. Therefore, once the business case is approved, we will focus on having an early win in the community around the EHR.
Mr. Richard Corbridge:
Deputy Kelleher commented on the 10,000 devices but it should be noted that it does not actually mean a single device for 10,000 people. It means enough additional devices in primary care and community settings to allow people to have access to a device. The days of queuing up to use an Excel spreadsheet on one machine in one community centre needs to end. We need to have more machines in more places in order that people can have access to that kit. It does not necessarily mean a piece of kit for every single person that is in the system. Predominantly, they would not use a single piece of kit each if it were deployed into the system. That has been seen across many jurisdictions. The aim is to improve the access to the systems that are there.
If one looks at the maternity and newborn system in Cork and Kerry, for example, we are rolling out a large number of new devices called computers-on-wheels in order that there are touch screens on wards, enabling people to access information as they pass by rather than being expected to carry their own device with them. That is a really big and important part of where we are going in that space.
On the issue of flexibility around contracts, the HSE works with the Office of the Government Chief Information Officer, OGCIO and the Office of Government Procurement, OGP, to make sure there are frameworks in place that do not lock us in to old equipment and to ensure we can continue to move forward. Things like mobile devices are in a good place in terms of the refresh rate, particularly in the past three years.
Compatibility with other jurisdictions is something that is very much EU-driven to allow the transfer of information. The IHI uses the same format as the NHS number which will give us the ability in the future to identify our patient information uniquely as if it were being shared with Northern Ireland or with the NHS. Behind the IHI is a code called the GS1, which is a global standard number that allows the number to identify a patient uniquely across the EU. The IHI has been built with exactly that in mind, which is very important.
The Deputy's last comments centred on collaboration and data analysis. Data analysis cannot be done easily today but with e-health Ireland in place, we will be able to conduct data analysis where it is appropriate, anonymised and where information is available. That is a key hook in terms of where we are going.
Mr. Richard Corbridge:
There is some resistance. As I have said, clinical engagement is phenomenal in Ireland, but in every cohort there will be some resistance. We deal with it by talking about the efficiencies, savings and the safety improvements that can accrue from this. We will slowly engage every clinical organisation throughout Ireland to ensure we can move forward with them and illustrate the benefits that digital solutions can bring to what they are delivering.
I have two brief questions. Has the HSE with the Revenue Commissioners, given the success of their systems? Is it likely that patients will be able to get access to information like the length of waiting lists? That would be very helpful in the sense that if one consultant has an 18-month waiting list while another one has a six-month list, patients could choose to be referred to the latter consultant. However, I know that this has been resisted traditionally by consultants. Has any progress been made on that?
Mr. Richard Corbridge:
We have consulted Revenue and its partners. The organisations with which Revenue worked actually helped us to create our knowledge and information plan and the operating model. We shared an awful lot of learning across those different areas.
Patients having access to waiting list information and information on referrals is digitally possible because of the e-referrals solution. It is a policy decision as to whether we open up that information, but digitally and technically it is absolutely possible to do so.