Oireachtas Joint and Select Committees
Wednesday, 25 January 2023
Joint Oireachtas Committee on Health
Electronic Health Records: Discussion
Seán Crowe (Dublin South West, Sinn Fein)
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As we have a quorum we will commence in public session. Apologies have been received from Deputy Colm Burke. At the outset I would like to convey sincere sympathies on behalf of the Joint Committee on Health to the family and friends of Mr. Matthew Healy who died in University Hospital Cork on Sunday. The committee is due to consider the issue of safety and the welfare of staff and patients in the health service on 8 February 2023.
Before we get to the main item of today's agenda, minutes of the meetings of 17 and 18 January 2023, have been circulated to members for consideration. Are they agreed? Agreed.
The purpose of today's meeting is for the Joint Committee on Health to consider the matter of electronic records in health care and related issues. This meeting will be divided into two sessions. The joint committee will first meet with representatives from the HSE from 9.30 a.m. to no later than 11.30 a.m. Following this the joint committee will meet with representatives from the Health Research Charities Ireland from 11.30 a.m. The meeting will end no later than 12.30 p.m.
To commence the committee's consideration of this matter I am pleased to welcome from the HSE, Mr. Fran Thompson, chief information officer, Mr. Michael Redmond, chief operating officer eHealth, and Dr. Brendan Murphy, consultant paediatrician and neonatologist previously in Cork University Hospital.
All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid 19.
Witnesses are reminded of the long-standing parliamentary practice that 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 or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.
Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House campus.
I invite Mr. Fran Thompson to make his opening statement on behalf of the HSE.
Mr. Fran Thompson:
Thank you. I wish the Chairman and members good morning. I thank the committee for the invitation to meet to discuss electronic health records, EHRs. I am joined by my colleagues Mr. Michael Redmond, chief operating officer e-health, and Dr. Brendan Murphy, consultant paediatrician and neonatologist previously in Cork University Hospital, now in University Hospital Waterford.
The HSE e-health vision is that e-health provides connected and complete digital patient records across all patient pathways and care settings. Implementing technology and e-health solutions and accelerating the digitisation of our health service are key enablers of delivering integrated care which will support the culture of continuous improvement and innovation. It will allow for increased access, sharing and analysis of information across the health service. Technology will provide predictive health delivery, identifying where services are needed most and supporting person-centred healthcare. Our technology and e-health solutions must be radically overhauled to provide the solutions required in a modern health service. Today, our health service is being held back by inefficient and often paper-based patient interactions, with the patient’s presence required due to a lack of tools, rather than patient need. While a patient’s presence is critical in a healthcare setting in some cases, it is not required in all settings. We need e-health platforms to allow information-sharing across care teams - with patient and service user consent - regardless of location or setting. This will optimise the efficiency of our healthcare staff while improving the experience of patients by delivering safe, integrated and high-quality care. By delivering these e-health platforms, we will be able to leverage appropriate innovative and emerging technologies that will enable a greater proportion of care to be delivered within community settings and allow patients to access care closer to home.
Insights are limited without good electronic information. Data and information are integral parts of the healthcare system and are essential supports for the delivery of high-quality and effective health and social care. People expect their healthcare information to be available to them and those responsible for helping them when and where they need it. At the same time, we want to assure them that their personal information is being handled appropriately, safely and securely in an approved and controlled way. Our current system lacks access to timely, accurate and robust data, which is essential for informing decision-making and assessing resource utilisation across operational, clinical and strategic departments. In 2018 and 2019, the HSE sought approval for procurement of a national electronic health record programme. This work included an electronic health record for acute and community services and provided a portal for patients to access their data. Approval was deferred in 2019 until a review of the outcomes of the Children's Health Ireland electronic health record was completed, which was approved. As a result of this decision, the HSE had to deliver multiple tactical solutions to digitise and deliver on the eHealth agenda. The reality however is that no matter how many point systems are delivered, from a holistic clinical and patient perspective, this approach will always be sub-optimal.
Concerning current solutions, there is a range of successfully-delivered digital solutions which fundamentally change service delivery at the front line. Examples include the national integrated medical imaging system, NIMIS, one of the largest in the world, which has fully digitised our radiology services, reduces waiting times for reports and ensures that services are provided in a safe and efficient manner. Another example is BloodTrack, a clinical bedside transfusion verification and transfusion software solution that electronically verifies that the right blood is being transfused to the right patient at the bedside. The national renal system facilitates clinical management of all patients with kidney diseases from first presentation to the renal centre and through to dialysis. The community audiology system is a community audiology solution which supports clinical teams delivering an audiology service. InterRAI assessment supports assessment of needs for care and social support. These are just a few examples.
While delivery and roll-out of these solutions have delivered significant value, the reality is that these solutions are tactical. Investments in e-health in the past were historically very low compared with other countries, which manifested in the inability to keep up with technology changes and limited our ability to deploy new solutions. Since 2020, that investment has increased considerably, with a 100% growth in staffing with an additional 400 ICT professionals and a 48% increase in capital expenditure, combined with a 230% growth in revenue expenditure. Rectifying the historical underspend will take several years, even with additional resources, but real progress is being made.
An electronic health record is a digital version of a patient’s paper chart. EHRs are real-time, patient-centred records that make information available instantly and securely to the authorised user. The benefits of an integrated EHR are well documented internationally and include the following examples. I will not go through all of them but I will highlight some of the main points. The benefits include a comprehensive view of patient records, which provides a dynamic, patient-centred record to enable clinicians to track patients over the continuum of care. Another benefit is seamless care pathways, as with digital records, clinicians can more easily co-ordinate and track patient care across practices and facilities. There may be a reduction in medical errors as digital records allow for better tracking and more standardised documentation of patient interactions, which has the potential to improve patient safety and reduce medical errors. Workflows are streamlined because EHRs increase the productivity and efficiency of clinicians while cutting down on paperwork. Patients and staff have fewer forms to fill out, leaving clinicians with more time to see patients. Data can be used to inform health strategy, as continuous data collection allows for greater personalisation of care, permitting providers to address health issues in a preventive manner. Big data analytics and aggregated patient data may alert providers of larger health trends such as potential outbreaks and which flu strains are predominant during flu season. There is greater efficiency and cost savings because digital records and integrated communication methods can significantly cut administrative overheads, including reducing the need for transcriptions and physical chart storage, as well as facilitating care co-ordination and reducing the time it takes for hard copy communication among clinicians, laboratories and pharmacies. An electric healthcare record is a key requirement for the efficient enablement of integrated care. It provides us with a North Star, or an ultimate destination for the digital transformation of our health service. Existing strategic investments and individual point solutions must be integrated into an electronic health record.
Today there are several examples of modern EHRs within the health service. St. James's hospital has an EHR for all its patients and four of our maternity hospitals also have an EHR. Cork University Maternity hospital, the maternity unit in Kerry University Hospital, the Rotunda Hospital and the National Maternity Hospital all share a common solution. Dr. Murphy has really good clinical experience in this area which he can share during this session. The board of the HSE has sanctioned the expansion of the newborn and maternal EHR to the Coombe Women's and Infants' University Hospital and to the maternity unit in Limerick University Hospital. This will start in 2023 and is scheduled to be completed in 2024.
The new children’s hospital has completed a procurement for an EHR for the hospital. The implementation of this solution is under way and on track to be delivered in tandem with the opening of the main hospital. In addition, we are deploying an EHR into the new facilities at the national forensic hospital and the national rehabilitation hospital. As well as the core system, each EHR implementation requires substantial associated people and ICT infrastructure investment to complement and maximise the core EHR investment. Deploying EHRs is challenging, complex and costly but the benefits are substantial. These are not one-off investments. They require continued sustained investment over their lifetime to ensure that they provide ongoing clinical and administrative benefits to both patients and clinicians.
A key principle for EHRs is that the data belongs to the patients. They own their data and they must have access to their record. They must be able to view the data and in an ideal world contribute to the record with data they generate, for example, through home blood pressure monitors. Part of the original national EHR proposal, which was not approved, was to deploy a patient-clinical portal. The HSE is in the process of updating a business case and has been in discussions with the Department of Health to ensure the success of the business case approval and overall project. The proposed portal will utilise the data from the existing HSE systems to populate the portal. Patients will have access to view their records and clinicians will have access to the portal to support them in their work. Patient-clinical portals are deployed in many European countries with considerable success. Existing electronic record data can populate the portal and if the national EHR is approved, it will populate the portal as well. The portal can bring together any clinical data into one location for viewing. As with all e-health solutions, the key principle will be data privacy by design.
Innovation takes place at many levels within the HSE - locally, regionally and nationally. The definition of innovation which is used is "the practical implementation of ideas that result in the introduction of new goods or services or improvement in offering goods or services". There are many examples of innovation within the HSE, within teams, within individual clinical and non-clinical locations, within wider regions and nationally. Innovation is a team effort. Clinical e-health innovation starts with an idea and then utilises the skills of existing staff, working together, to bring this to completion. The proposed solution must be clinically safe, it must integrate with existing processes and it must share and receive data with other parts of the health care system. It must be funded, sustainable and must comply with existing laws on procurement and data protection. Having an idea is just the start of the process. Turning that idea into a successful pilot and then scaling the idea in a sustainable way is essential. For clinical innovations, e-health works in partnership with the chief clinical information officer who is part of the chief clinical officers team.
There are many brilliant examples of clinical innovations across the wider HSE and, in particular, within e-health. Video-enabled care, for example, utilises collaboration tools to enable the patient to be seen virtually, where clinically safe. Over 360,000 remote consultations have taken place in the past two years. E-prescribing enables GPs to safely send prescriptions via the HSE's HealthMail service to nominated pharmacies, thus reducing transcription errors and allowing for repeat prescriptions to be sought virtually. Remote respiratory rate monitoring, is live in 22 hospitals over 40 wards. More than 2,000 healthcare professionals have been trained in its use. On average, two patients per ward are monitored remotely, with admission on diagnosis of COPD, pneumonia, asthma and so on. These and many other innovations were undertaken in partnership with the clinical community. They integrate with our existing solutions and are scalable across the whole organisation. That concludes my opening statement.
Seán Crowe (Dublin South West, Sinn Fein)
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Thank you very much Mr. Thompson. I will now invite committee members and other Members of the Houses to discuss matters with the witnesses. Deputy Durkan is first and I understand he is on the Leinster House campus.
Bernard Durkan (Kildare North, Fine Gael)
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Yes. Thank you Chairman and thanks to our guests this morning for their opening address. What are the areas of most concern for healthcare providers? What are the most sensitive areas, the most essential areas and what has been the progress to date in delivering solutions?
Mr. Fran Thompson:
I thank the Deputy for his question. The most important areas for us include the children's hospital, which is a brand new facility. Every time we open a brand new facility we try to ensure that we provide the correct and efficient digital solutions in that area. We have made significant investment in the maternity solutions and we want to expand that out to other hospitals. We are also investing in the forensic hospital and the rehabilitation hospital to provide them with really modern, up to date digital solutions that match the infrastructure that is being put in. Lots of parts of the health system require digital solutions and it is challenging. It is also not possible to say that one area needs it more than others. What we try to do is work with both the clinical community and our own IT community to ensure that we deliver the services that are required.
Bernard Durkan (Kildare North, Fine Gael)
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Where are the most deficient areas at the present time? To what extent is the HSE working towards solutions that are in keeping with the demand? As the population grows and as the instances requiring digital solutions increase, what are the most sensitive areas and where has the most progress been made?
Mr. Fran Thompson:
In terms of the areas that are deficient, I would start with us providing data. We have a lot of data and information and the issue is to provide that directly to the patient. We are definitely behind other countries in that regard. I went on a trip to Finland to have a look at its portal. The Finnish portal allows people to book appointments, see their record and engage with their clinician electronically and digitally. Telephone support is provided for people who cannot communicate electronically and digitally.
This is an area of real concern because most patients want access to their record. There are other areas in the core with regard to the EHR. In order to manage care successfully, digitising the process at every level, including in hospital and community settings, is really important. That is why we are looking at the EHR. I will invite Dr. Murphy to contribute on this because he has real experience of digitisation within the hospital setting.
Dr. Brendan Murphy:
My experience is in the acute care setting. I am a paediatrician and neonatologist. In the acute setting of acute maternity care for mothers and newborns, the advantages of the digital record speak for themselves. It provides immediate access to a record across the healthcare team, with multiple users having access to that information to provide care at the same time. It allows for communication across the record across locations. Essentially, it makes it possible to move information rather than, at times, moving critically ill patients, for example. We have had multiple examples of that in terms of mothers and newborns across the four live sites.
Currently, the potential to move and share information rather than moving patients is a very real advantage with immediate access to care.
Mr. Fran Thompson:
If I could add one other thing, and I should have said it earlier, the other deficiency is the integration between acute and community settings. When patients are being discharged from acute and moving into community, that there is integration of the data. This is where the shared care record portal would really come in. A lot of that integration is being handled manually today.
Bernard Durkan (Kildare North, Fine Gael)
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Why was an underspend recorded in some areas? Given the essential nature of the need to install the services fully for the benefit of the patients and delivery of the services, why the underspend? How did that come about?
Mr. Fran Thompson:
I am not sure. In the past four years, we have spent more than 99% of our capital every year. We have also fully spent on the revenue side. I might ask my colleague Mr. Redmond to come in because he manages that. We have continually fully spent all of our allocation over the past number of years.
Mr. Michael Redmond:
That is true. Since about 2015, our capital budget has grown from €40 million, through to €55 million and €65 million, up to where it is for this year, which is €140 million. In every one of those years, we invested 99% of that money in digital. That is a reflection of the need for it. Equally, as the e-health capability within health and within the HSE has grown, and in fairness there has been increased investment in the past few years, we have been maximising that investment. We certainly have not left an underspend behind us.
Bernard Durkan (Kildare North, Fine Gael)
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With regard to the new children's hospital, and other institutions, can the witnesses identify at this stage the most sensitive areas where progress under this heading is most needed?
Mr. Fran Thompson:
When we look at the two hospitals that are there at the moment, namely, Crumlin and Temple Street, they are both lacking integrated electronic healthcare records and digitising. For the new children's hospital, the rationale for an electronic healthcare record is to ensure we can provide children with the most safe and effective service that is digitally enabled, both for them and for the clinicians so that from the start of their journey to the end, it is fully digitised. That is the goal and the effort that is being made in the children's hospital. We are supporting that fully and working with the children's hospital. The procurement for the electronic health records has been completed and they are now starting to work on the implementation of the project. It is approximately a 20-month project. That will enable the children's hospital to open in a digitised fashion.
Bernard Durkan (Kildare North, Fine Gael)
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How safe are the HSE systems? How foolproof are they? Can they withstand electronic attacks, or whatever the case may be? We know what happened in the past. That was through no fault of the witnesses but it happened. How can the HSE prevent that and protect records against an attack of that nature in the future?
Mr. Fran Thompson:
Since the attack we have substantially invested in cybersecurity. We put in an additional 23 staff in 2021-22 and we are putting in an additional 43 this year on the cybersecurity side. We also quite heavily utilise cybersecurity expertise across the country. Last year we had approximately 48,000 cyber alerts to our dashboards. Those cyber alerts get investigated and some of those could turn into a threat. We have managed to stop those and managed to work with all of our cyber expertise. Cyber expertise is not just one or two people. It is a collaboration of everybody working in the HSE who has digital solutions, first, to guard and make sure they are not being phished. There is phishing going on where people are trying to get information out of them and there is a lot of education that goes on to ensure people are aware of that and know about it. We have mandatory courses on that. Then we have our cyber expertise. We draw both internally and externally to defend the organisation. It is a constant arms race. Cybersecurity requires continual and sustained investment. We have also brought in a senior chief information security officer, CISO, who is in charge of that area and who reports directly to the CEO to ensure we provide as safe and secure a service as possible.
Bernard Durkan (Kildare North, Fine Gael)
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Is the investment to date adequate and sufficient to meet the challenges? I am talking about both the security challenges and the need to spread the technology to all areas as quickly and effectively as possible.
Mr. Fran Thompson:
An additional once-off investment of €40 million was made for 2023. We are in discussions with the Department of Health to make that an annual investment to ensure we can continue the work we have started around defending the organisation. It is a multi-year task that requires ongoing and sustained investment in both people and capital and revenue costs.
Bernard Durkan (Kildare North, Fine Gael)
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The last question-----
Seán Crowe (Dublin South West, Sinn Fein)
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The Deputy has run out of time; I am sorry.
Bernard Durkan (Kildare North, Fine Gael)
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I am just at ten minutes.
Seán Crowe (Dublin South West, Sinn Fein)
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You are over ten minutes, according to the clock.
Bernard Durkan (Kildare North, Fine Gael)
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Not according to my clock here. Maybe my clock is not as early.
Seán Crowe (Dublin South West, Sinn Fein)
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The Deputy can ask his question and then we will move on.
Bernard Durkan (Kildare North, Fine Gael)
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I do not go over time normally.
Seán Crowe (Dublin South West, Sinn Fein)
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Go on. Ask the last question.
Bernard Durkan (Kildare North, Fine Gael)
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Regarding the proposals made and still outstanding, what efforts are being made to accelerate them?
Mr. Fran Thompson:
On the proposal side, we have a good process that we work through with the Departments of Health, and Public Expenditure and Reform to bring proposals from idea right through to approval, procurement and implementation. At the moment, to the best of my knowledge, there are no outstanding proposals sitting with the Departments of Health or Public Expenditure and Reform. We are working on a business case for the portal and we will be, once we go through the strategy, working with both Departments on an updated EHR proposal.
Seán Crowe (Dublin South West, Sinn Fein)
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Just to come back to Deputy Durkan's question, how many attacks were there per year?
Mr. Fran Thompson:
We have a dashboard that manages them all. We would have had approximately 48,000 alerts. Not all of them would be actual attacks. Some would be benign where the system picked up that there may be something there. All of those get looked at. We would have had approximately 1,200 investigations and there are more than 200 that are significant.
David Cullinane (Waterford, Sinn Fein)
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I just want to pick up on that theme first before I go into more substantial questions. Cybersecurity is important as we roll out more investment in e-health and digitisation. Has the system totally recovered from the most recent hack or cyberattack, which was quite substantial across our health services?
Mr. Fran Thompson:
I would say the system has totally recovered. Looking internationally, with any attack there is always some item that may come up as an issue but we are treating that as business as usual and working through any of those issues that come up as business as usual. An example would be that we have shut down a lot of access across systems to protect them. Somebody might run something once a year or every two years and they suddenly find they cannot run it. They get onto our helpdesk and we then work with those people-----
David Cullinane (Waterford, Sinn Fein)
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Okay, so it is substantially recovered.
David Cullinane (Waterford, Sinn Fein)
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The figures given are quite stark. There were 48,000 alerts. As Mr. Thompson said, a lot of those are benign. There were 1,200 investigations and 200 of those are significant. Is there any relationship between any of those hacks, even the most recent substantial one, and the fake texts people were getting purporting to be from the HSE about antigen tests and other areas?
Is there any relationship between hacks and those texts or is that seen as separate?
Mr. Fran Thompson:
It is seen as separate and to the best of our knowledge and working with some of the security experts around it, many of the texts people are getting are not just around the HSE. They are getting them from other State areas as well such as An Garda Síochána, Revenue, social welfare-----
David Cullinane (Waterford, Sinn Fein)
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There is no relationship then between hacks and that information?.
David Cullinane (Waterford, Sinn Fein)
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On the issue of the substantial issue of investment in e-health, Mr. Thompson's opening statement was quite frank regarding where we are at because he rightly said that implementing technology and e-health solutions is a key enabler to the delivery of integrated care. He goes on to say:
Our technology and e-health solutions need to be radically overhauled in order to provide the type of solutions required for a modern health service. Today our health service is being held back with inefficient, and often paper based patient interactions, with a patient’s presence required due to the lack of tools rather than the patient need.
I am struck that even with a lot of what is being planned, we are a long way away from where we need to be. We are not using unique patient identifiers in the way we should; we do not have electronic records operating across the health service anywhere near the level we should; we do not have integrated IT systems across many areas, and we have heard for a long time about the need for an integrated financial management system, integrated waiting list management systems and so on. There is, therefore, a long road to travel before we can get to a point where Mr. Thompson can say that the service is not held back because of the lack of solutions and investments in this area. Will he comment on that first?
Mr. Fran Thompson:
I will try to comment on some of those points. I will start with the integrated health identifier, IHI. We are in the process of rolling out the IHI. We have had the IHI index for a number of years. I will give some examples of numbers. The primary care reimbursement service, PCRS, has approximately 9 million IHIs, including medical cards, GP visit cards, drug repayments, long-term illness, and the hi-tech. National screening has approximately 4.6 million IHIs, cutting across CervicalCheck, BreastCheck, renal and bowel screening. The national schools immunisation programme has approximately 1.5 million. We are really working through these. On the Covid-19 side, 5 million IHIs were provided. GPs on public practice were provided with IHIs towards the end of the year and we are working----
David Cullinane (Waterford, Sinn Fein)
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All of that is in Mr. Thompson's opening statement. I am only quoting what he said. It is not my language, even though I agree with what he has said. He said that our technology and e-health solutions need to be radically overhauled and that our system is being held back because we do not have those integrated IT solutions, electronic patient record systems and all of those systems that should be up and running. When people hear about something being in the process of being rolled out, these are issues we have been talking about for decades and we are still in the process of rolling them out. I do not know how long that is going to take. From my understanding of it, I assume it will not be done any time soon anyway. I am saying to Mr Thompson using his own words that we have a long road to travel. Would he accept that? It is going to take time to get to a place where we-----
David Cullinane (Waterford, Sinn Fein)
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The former head of digitisation, who as Mr. Thompson knows resigned from the HSE, is on record today - it is timely because it was covered substantially in The Irish Timestoday - stating that the HSE has "no vision" for e-health and efforts to change this are being impeded by "bad actors". Is that something with which Mr. Thompson agrees or has experienced?
David Cullinane (Waterford, Sinn Fein)
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Mr. Thompson can give his opinion. I am asking for his opinion.
Mr. Fran Thompson:
I will outline the vision that the HSE has. We called out the vision in the opening statement very clearly. We have a vision to provide connected and complete digital patient records across all patient pathways and care settings. We are working to do that. Huge numbers of innovative solutions have been deployed across the totality of the HSE, nationally and locally and down to ward-level. People will have seen the e-prescriptions which enable GPs to utilise our existing technology stack to electronically send prescriptions, saving patients having to walk into hospital. These are being done at scale, massively.
David Cullinane (Waterford, Sinn Fein)
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I accept that. It is actually one of the areas where we have gotten it right. E-prescription is a big success. I certainly agree with that but we are way behind in all the other areas. On funding, Mr. Thompson spoke earlier about the capital and revenue funding stating that we hit 99% of the spend on what is allocated. Money also comes or is available as well through the recovery and resilience fund. My understanding was that €75 million was available to Ireland under that fund, of which €40 million was for e-pharmacy and €35 million for financial systems. How much of that money was spent?
David Cullinane (Waterford, Sinn Fein)
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How much of it is spent so far? Is there not is a time limit on that?
David Cullinane (Waterford, Sinn Fein)
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The figure I received in a parliamentary question response was quite lo#; it was only a fraction of the money that was allocated. While it may be the case that in terms of voted expenditure for both current and capital, the HSE hitting 99%, it does not seem to be the case under this resilience fund money that the same target is being reached. I could be wrong. I imagine if Mr. Thompson is primarily responsible for e-health and delivery of spend, that €75 million is substantial money and he should know how much of it is spent.
Mr. Michael Redmond:
If I could come in there, I will say two things about that. That money is drawn down by the Department and then allocated to us through capital expenditure, which we maximise every single year. We are behind for the period of time that the national recovery and resilience plan, NRRP, mentioned by the Deputy------
David Cullinane (Waterford, Sinn Fein)
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Why?
Mr. Michael Redmond:
I can tell the Deputy why we are behind. During 2020 and 2021, most of our efforts were diverted from what was our e-health plan for those two years, first, by the pandemic, which obviously stretched into 2021 and we know what happened in 2021 as well. Both of those years substantially knocked us off course. We delivered many other good and innovative digital solutions that have proven to be pathfinders for us in terms of test and trace and vaccination systems but nevertheless they were not on the start-of-year plan that year for obvious reasons. The things we were going to do that year were suspended for a while. We are back on track and in discussions with the Department even as late as last week. We are back on track to drawn down that money fully before the time limit expires.
David Cullinane (Waterford, Sinn Fein)
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We need to be assured that money will be spent. With all the investments that are needed, it would be intolerable if that money was not spent. My understanding is that there are rules around how and when that money can and should be spent.
My last question relates to the next session we are going to have with Health Research Charities Ireland, HRCI. Its representatives talk about a document being launched, which is the 2023 HRCI position paper. I ask that the HSE gives that paper serious consideration because it outlines three priorities, namely the implementation of a national electronic health record, on which I assume Mr. Redmond will agree, but also supports for genetics and genomics research, and the establishment of research support functions within the HSE. It is a very valuable and worthwhile study and certainly something to which Mr. Redmond and Mr. Thompson should give serious consideration. I assume they will hear the interactions the committee will have with that group later but to do the HRCI justice while the representatives from the HSE are here, I flag that study and report as important.
Mr. Fran Thompson:
I agree Deputy. I am aware the chief clinical officer of the electronic health programme has set up a strategy group around the genomics side of it. It is a real area in which we can make a huge difference. As the Deputy will be aware, any of the genomics side of things requires significant ICT and e-health investment as well.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank the witnesses and ask that they provide the committee with a written note on that European money.
Róisín Shortall (Dublin North West, Social Democrats)
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I welcome the witnesses to the meeting. On reading Mr. Thompson's opening statement and listening to his presentation, with all due respect to himself and Mr Redmond as I do not know where the blame lies, I despair when I hear the tone of the opening statement. Mr Thompson is talking about the theoretical benefits of e-health and nobody will argue with any of them for a moment. Why are we talking on a theoretical level and about things happening in the future when the e-health programme was in development in 2013 and was announced in 2015?
The reality is that Mr. Thompson could have given the same opening statement any year for the past ten years.
Róisín Shortall (Dublin North West, Social Democrats)
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Sorry, I am not finished.
Róisín Shortall (Dublin North West, Social Democrats)
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Our job today is to try to find out why on earth we seem to be incapable of delivering a proper modern e-health programme within the health service. It is so fundamental to everything about the health service. If we are serious about reform and serious about introducing the Sláintecare programme, we just have to get this right. We have to find out why has it not been got right for so many years. Where does the problem lie? In August 2022, HIQA said that we have a huge mountain to climb to reach any kind of EU standard in this. There have been various promises over the years, but it is just impossible to understand why on earth we are such laggards and why we are so far behind in this strategy. I am not necessarily pointing the finger at Mr. Thompson, because I do not know where the fault lies. We had the 2015 plan. That was supposed to be implemented and funded fully. I think the price tag was just under €900 million. It was €895 million or something like that, if I recall correctly. This has been gone into in considerable detail within the Sláintecare considerations. There was an urging to accelerate the implementation of this and to do it over five years rather than ten years. Can the witness tell us what strategy he is working to at the moment? Is it the 2015 strategy?
Róisín Shortall (Dublin North West, Social Democrats)
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I do not want to talk about individual aspects of this, because the key thing is having a strategy. What we have is different GPs using different systems. We have different hospitals using different systems. There appears to be no overall strategy being implemented. Is Mr. Thompson still working theoretically to the 2015 strategy?
Róisín Shortall (Dublin North West, Social Democrats)
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Why not?
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. It was a funding issue.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. Funding and capacity to deliver are issues. Why did we not have the capacity to deliver?
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. It is the personnel capacity.
Róisín Shortall (Dublin North West, Social Democrats)
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Is the 2015 strategy still the strategy Mr. Thompson is supposedly working to?
Róisín Shortall (Dublin North West, Social Democrats)
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What does Mr. Thompson mean by "ultimately"?
Róisín Shortall (Dublin North West, Social Democrats)
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Mr. Thompson says "tactical", but what I am hearing is piecemeal, rather than working to an overall strategy, which is now coming up to eight years old.
Róisín Shortall (Dublin North West, Social Democrats)
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Because the HSE did not have the capacity and did not have the funding. Is that what Mr. Thompson is saying?
Róisín Shortall (Dublin North West, Social Democrats)
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Yes, okay. Is there an intention to have a new strategy?
Mr. Fran Thompson:
Yes, Deputy. The Department of Health has started working on a new strategy and it is for quarter 1 this year. That is just to put a timeline on it. We will then take that overall strategy around policy direction into the HSE and put in a timed implementation on it.
Róisín Shortall (Dublin North West, Social Democrats)
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It strikes me from what Mr. Thompson has said that, yet again, the health service is to be shook up with a new plan and a new strategy without implementing the existing one. Can Mr. Thompson tell us in simple terms why we need a new strategy? Is there a problem with the 2015 strategy? Was it not comprehensive enough? Why is a new strategy now being devised?
Róisín Shortall (Dublin North West, Social Democrats)
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This is more moving of the deckchairs. How is it that we cannot have a strategy, implement it, fund it, give the approvals to it and make it happen? Here we are now going back to a new strategy. Is it not possible for the HSE to work with the 2015 strategy and update it as it goes along?
Róisín Shortall (Dublin North West, Social Democrats)
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Who is ultimately responsible for implementing the e-health strategy?
Mr. Fran Thompson:
Ultimately, the e-health strategy will be delivered by a combination of ourselves in e-health and the clinical community with Dr. Colm Henry and people like Dr. Brendan Murphy. However, we have to get to the starting line. We have to go through the approvals process and the procurement process to get to that starting line.
Róisín Shortall (Dublin North West, Social Democrats)
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I am sorry. Please, is Mr. Thompson saying we have to get to the starting line?
Róisín Shortall (Dublin North West, Social Democrats)
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What does that mean?
Róisín Shortall (Dublin North West, Social Democrats)
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Wait. Mr. Thompson has spoken about getting through a programme and getting to the starting line. Is he saying that we are not midstream in a programme or strategy at the moment? How is it that after eight years, we are talking about needing to get to the starting line?
Róisín Shortall (Dublin North West, Social Democrats)
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What are the main reasons we do not have an EHR after eight years?
Mr. Fran Thompson:
There are a couple of reasons for it, as I said in an earlier answer. First, we put forward our business case to the Department of Public Expenditure and Reform, which was not accepted. It is around capacity and around the people and additional bodies on our side of it. The ability of the organisation to make some of the big transformations that were required was seen as a rationale for why it did not get approval. However, in the meantime we have the-----
Róisín Shortall (Dublin North West, Social Democrats)
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I am sorry. The Department of Public Expenditure and Reform was questioning the system's ability to actually implement the strategy. Is that right?
Róisín Shortall (Dublin North West, Social Democrats)
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What was done in relation to that?
Róisín Shortall (Dublin North West, Social Democrats)
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Is it the case therefore that the expertise was not within the HSE?
Róisín Shortall (Dublin North West, Social Democrats)
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No, I do not want to hear about individual examples.
Róisín Shortall (Dublin North West, Social Democrats)
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That is fine, but we are talking today about the e-health strategy. I want to know why it is that we are so off-course and so behind in implementing an eight-year strategy.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay, but there is this kind of passing of the parcel between the HSE, the Department of Health and the Department of Public Expenditure and Reform. The Minister of State, Deputy Ossian Smyth, comes into it as well. Where does responsibility lie? Who is driving this, if anyone?
Róisín Shortall (Dublin North West, Social Democrats)
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The HSE is waiting for the approval of-----
Seán Crowe (Dublin South West, Sinn Fein)
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I call Deputy Cathal Crowe.
Cathal Crowe (Clare, Fianna Fail)
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I thank the witnesses for attending this morning. Is it not an awful indictment that there is more known about each one of our cars through the national car test database than there is about our public health?
If I look up 141 CE 122, which is the registration number of my Honda car, I can see that much more is known about the wear and tear on the front right tyre and the wishbone joint than there is about my personal health or that of anyone else in the country. A person with whom I have been engaging a lot in my office exemplifies this. They recently had a hospital stay. The stay was quite good and they got a good level of care. On the day of discharge when the family came to take the person home, there was a warm "thank you" in the corridor before they got into the car. In passing, this elderly person said it was the third health battle they had won in recent years, as they had overcome cancer. All the jaws dropped because nobody there had known this patient had had cancer. Even though it is clear how relevant that is to a patient's medical history, it was not known. Perhaps it was in some file that had not been dusted down or brought over. It is so cumbersome. It is wrong that there is more known about scooters, cars, trucks and vans than there is about our personal health.
The HSE officials have spoken about the strategy going forward and many members have asked where that is at, but I want to know about the here and now. Until the HSE gets this electronic records system fully operational, where are all the paper records stored? If somebody has been living within the curtilage of the Saolta Hospital Group but then moves down the UL Hospitals Group, does that record come with them? What sharing of records between hospital groups is there? What is there already, or is there any uniformity at all?
Dr. Brendan Murphy:
This is complex and challenging and I agree the availability of information in a paper-based system is cumbersome, slow and inefficient. To respond to Deputy Shortall as well, I have been involved in the design, build and implementation of what I consider to be the pathfinder project in the maternity and newborn system for more than ten years now. I have seen and derived the benefits of that. However, I am very aware of the complexities involved. To me, this is not a simple solution that involves just going in and buying a disc off the shelf, putting it in the machine and having everything work out fine. To me, an electronic health record is a clinical programme that is clinically enabled with strict governance to try to make it as safe and efficient as possible with the patient at the centre. It would make the information, as the Americans say, "Nothing about me without me" but at the same time-----
Cathal Crowe (Clare, Fianna Fail)
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I ask Dr. Murphy to answer the question. What paper system is there if someone from Galway moves down to Clare and then on to Wexford? What travels with a patient around the country?
Cathal Crowe (Clare, Fianna Fail)
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I know what is intended but what is there at the moment? I really need to get an answer on this. Is there anything being forwarded at all?
Cathal Crowe (Clare, Fianna Fail)
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We heard that. What is there at the moment for a guy or girl who comes into accident and emergency with something chronic and painful? Let us say they need treatment there and then, and they are admitted. What follows them from a hospital they have already been in?
Cathal Crowe (Clare, Fianna Fail)
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Can the officials just-----
Cathal Crowe (Clare, Fianna Fail)
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We have half the speaking time. Is there any uniformity whatsoever? Is there any paper record that will travel with Joe or Jill Bloggs as they go through one hospital system to another? Is there any uniformity?
Cathal Crowe (Clare, Fianna Fail)
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Okay. We got to that eventually. Is there not a huge risk in that? I was in accident and emergency a few years ago with a concussion on the back of my head and the first 40 minutes or so were spent in triage. It was all questions about date of birth, PPS number and all of those things. If someone is coming in concussed or bleeding heavily from an injury, those initial moments should be spent retrieving a record rather than trying to find out who this person is, where they live, what their PPS number is and who is their next of kin. There is so much time wasted. There is a team dealing with an e-strategy that seems light years away yet there is no information officer in accident and emergency apart from at the reception desk when you are going in. The triage nurse spends way too much time trying to write reams of paper to find out who is this person and what is wrong with them before he or she passes them to the doctors and medical team. Do the officials think there a risk in that? Is there a delay and a risk in accident and emergency in this current system?
Dr. Brendan Murphy:
In the health service, whether it is triage or the acute care setting I work in, care comes first and documentation of the information comes afterwards. Therefore, I suspect that in the acute phase of the bleeding patient, the patient would be dealt with first and foremost. Yes, there are clinical risks in the absence of an electronic health record. An electronic record, in and of itself, brings with it risks unless it is managed appropriately and designed and built effectively. It is not just about having data; you need to have data that are useful as information, provide knowledge to the caregivers and can be communicated effectively across the healthcare team to provide the best care. If this was simple, I believe, based on the experience I have had, that we would have done it years ago - not just in this jurisdiction but elsewhere.
Cathal Crowe (Clare, Fianna Fail)
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If doing this internally - having an Irish system for an Irish problem - is taking so much time, why can we not go internationally? I hope this is not a clumsy analogy but I am on the transport committee and the Irish Aviation Authority, IAA, is believed to have systems so far advanced internationally that it is now able to contract them out to other countries. Surely the NHS or other health systems have e-records that are far above what other countries do? Surely we can contract somebody? The IAA is going out to Greece. Surely we can get an EU or international system in here by contracting it out. Is that possible? Has it been explored?
Cathal Crowe (Clare, Fianna Fail)
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Has the HSE asked any international partners whether they can help to deliver this in full or in part?
Dr. Brendan Murphy:
We are working with one of the two main vendors of electronic health records in the US. It deals with more than 40% of health records across that country as a partner in working to implement the maternity and newborn system. Even then, it is not a question of just taking that vendor's generic system. Whether it is in a single hospital, region or jurisdiction, one always has to work with the system so it works with the clinical workflows and the care provided.
Cathal Crowe (Clare, Fianna Fail)
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In advance of having this system, whenever it comes, has the HSE given any advice, circulars or guidance to practitioners around the country on the need to get to a point of alignment? It seems there is none at the moment.
Cathal Crowe (Clare, Fianna Fail)
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Between now and then, should there be information officers at accident and emergency departments so that we are not tying up a clinical nurse with clipboards trying to find out who you are, where you are from and what your PPS number is?
Dr. Brendan Murphy:
If the answer was as simple as an information officer in the emergency department for our complex care system across the acute and community settings - I think there is a need for a more integrated approach for the movement of information rather than patients across the system-----
Cathal Crowe (Clare, Fianna Fail)
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As a final point, sometimes opportunities pass people by. There were two really quickly delivered protocols here in the last two years. One was the digital Covid certificates. I was going to say we all had them on our phones but some people bought in and some did not. However, most people were embracing vaccines, the technology that went into the certification, etc, and people adapted very quickly to that. Was the obvious thing not to build on that and on e-prescriptions, which were digital foundations? I do not think anyone in the country is checking their online Covid tracker anymore. Certification has pretty much become dormant. Was that not the golden opportunity to go one-nil up that the HSE let pass by?
Mr. Fran Thompson:
We are not letting it pass us by. We have a team and are starting to work around taking the Covid tracker app and repurposing it and utilising some of the technologies at the back end of that as the electronic front door to provide people with some access to what is there already. It will also provide them with a digital wallet, which is being widely rolled-out in other EU countries. There is an EU standard around that. We are looking at that and have it in our capital plan for this year.
Cathal Crowe (Clare, Fianna Fail)
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Okay. Until our guests get to a standardised e-platform nationally would they not, as the information team at the HSE, communicate with each hospital group and tell them to stop operating as silos? Would they not say that at least until we get to point X, we will operate on some standardised record-keeping system? If the team is focused in the long term on e-health, it is not dealing with the current record system in the short term.
Cathal Crowe (Clare, Fianna Fail)
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My question was about non-electronic health records. The records are not yet online. At least the paper records should be standardised. Mr. Thompson said five minutes ago there is no uniformity. Surely the first thing to do would be to get some uniformity while continuing with the long-term plan for electronic health records. Those going into emergency departments today would like to know that some uniformity is being developed even if it is on paper for now.
Neasa Hourigan (Dublin Central, Green Party)
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I welcome the witnesses. I was very keen to have this session, mostly because I am interested in evidence-based design. I had quite detailed questions on it but we might need to start at a different place from where I intended. I had not realised we had not got to the start line on some of the digital e-health projects. I want to go back to that discussion. To be clear, when was the business case for electronic health records rejected?
Neasa Hourigan (Dublin Central, Green Party)
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I am sorry. Would Mr. Thompson repeat that? The Department said it would not give the HSE capital funding to go ahead with this vital project until it could see it in operation in the national children's hospital, which has a massive time overrun. That is where the business case fell down. It could not be proved even though it is operating in all of the countries all around the world. That is how good health systems work. It could not be proved because it was not working in a project that was not even up and running at the time.
Neasa Hourigan (Dublin Central, Green Party)
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That was in 2018. Everyone in the room knows it is now 2023 and the hospital is still not open. The business case was rejected in 2018. Is the HSE still waiting for it to be in operation in the national children's hospital before we can move forward?
Neasa Hourigan (Dublin Central, Green Party)
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I know we are nearly at the end of the era of completing the national children's hospital but if it is to be used as an example, it would require 12 or 18 months of data. This will push it very far out. Surely the Department of Public Expenditure and Reform can see this is not a reasonable way to make a decision. If it accepts that point, how long will it take the HSE to do the business case? How long did it take in the case of the partnership with the US company with regard to newborns, for example? How long will it take the HSE to move through the procurement process?
Neasa Hourigan (Dublin Central, Green Party)
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Has it been updated?
Neasa Hourigan (Dublin Central, Green Party)
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The HSE has known since 2018 that the business case was not fit for purpose.
Neasa Hourigan (Dublin Central, Green Party)
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Did it refer to the national children's hospital?
Neasa Hourigan (Dublin Central, Green Party)
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Then it is not fit for purpose.
Neasa Hourigan (Dublin Central, Green Party)
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The business case for ICT in the national children's hospital must have been written down in 2009.
Neasa Hourigan (Dublin Central, Green Party)
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The HSE is still linking the rest of the EHR to the national children's hospital.
Neasa Hourigan (Dublin Central, Green Party)
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I do not mean to cut across Mr. Thompson but I have only six minutes. To learn from the electronic healthcare records process in the national children's hospital, that hospital will have to be up and running and we will need a certain cohort of data. How do we get this, starting now, without having to wait 12 or 18 months for the hospital to be open? By the way, it will not be until the middle of next year that it will be open and we will be able to commission.
Neasa Hourigan (Dublin Central, Green Party)
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How do we know whether an EHR system is working if we do not have patients to test it against and if it is simply just commissioned in the building?
Neasa Hourigan (Dublin Central, Green Party)
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Mr. Thompson, I know about commissioning in healthcare building.
Neasa Hourigan (Dublin Central, Green Party)
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There needs to be an occupancy record to show it is working.
Neasa Hourigan (Dublin Central, Green Party)
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It requires at least 12 months up to 18 months.
Neasa Hourigan (Dublin Central, Green Party)
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We are still waiting for that system to be in place before we move to the business case for the rest of the healthcare system and a procurement process.
Neasa Hourigan (Dublin Central, Green Party)
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Will Mr. Thompson give me a timeline for this?
Neasa Hourigan (Dublin Central, Green Party)
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No, a timeline for the completion rather than the starting.
Neasa Hourigan (Dublin Central, Green Party)
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What about a ballpark? Let us start with when the HSE is going to start.
Neasa Hourigan (Dublin Central, Green Party)
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We have been working on this since 2013.
Neasa Hourigan (Dublin Central, Green Party)
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From 2018, other than on the newborn system, all work on electronic healthcare records ceased.
Neasa Hourigan (Dublin Central, Green Party)
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What does that mean? Was it hospital by hospital?
Neasa Hourigan (Dublin Central, Green Party)
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The point of electronic records is that they are global in that they encapsulate all information. If the information continues to be spotted for five or more years, what is the benefit? It seems incredible we are here in 2023 when we set off on this journey in 2013. It seems we have not even started the work.
Neasa Hourigan (Dublin Central, Green Party)
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I completely accept that. My point is that it is a flawed methodology to link this to a particular hospital when that hospital has been desperately delayed for many years.
Neasa Hourigan (Dublin Central, Green Party)
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I would like to be asking more detailed questions about its operation. I had many questions on the capacity for data collection and how we will link it to staffing. I do not see any point in asking them when we are at this stage.
Neasa Hourigan (Dublin Central, Green Party)
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We will speak to another group after this session. Will electronic healthcare records be deployed for the sake of evidence-based decision-making and disaggregated data? I sit on many committees and the lack of disaggregated data comes up almost every week. The HSE and the Department of Social Protection are the key players in this.
Neasa Hourigan (Dublin Central, Green Party)
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Is the HSE making headway in establishing research support functions for universities and whoever might require those disaggregated data or any other data?
Mr. Fran Thompson:
There is a research part of the HSE that works with those colleges and others. Until now, we have not provided access to our data.
Neasa Hourigan (Dublin Central, Green Party)
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Are there plans to do so when EHR is fully operational?
Neasa Hourigan (Dublin Central, Green Party)
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I do not see any discussion around the health information Bill in Mr. Thompson's opening statement. Is the HSE working with drafters on it? Is Mr. Thompson involved in the process?
Neasa Hourigan (Dublin Central, Green Party)
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When was the last time the HSE was consulted?
Neasa Hourigan (Dublin Central, Green Party)
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Does Mr. Thompson mean 2022?
Seán Crowe (Dublin South West, Sinn Fein)
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Would it be helpful if the committee were to try to make some sense of the 2018 decision by the Department of Public Expenditure and Reform?
Neasa Hourigan (Dublin Central, Green Party)
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Are we allowed a business case or a rundown of the reasons it was rejected?
Seán Crowe (Dublin South West, Sinn Fein)
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We can ask.
Martin Conway (Fine Gael)
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The committee should write to the Department-----
Seán Crowe (Dublin South West, Sinn Fein)
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I was just about to suggest that.
Martin Conway (Fine Gael)
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-----to seek an explanation as to its rationale for delaying it until after the national children's hospital is completed, given the number of delays.
Neasa Hourigan (Dublin Central, Green Party)
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Even linking the EHR with the children's hospital will delay it.
Róisín Shortall (Dublin North West, Social Democrats)
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The importance of this is such that we need to arrange a special or urgent session on this. The senior people in the Department of Public Expenditure and Reform responsible for this and for the decision in 2018 should be brought before us. What I am not clear about is the exact role of the Minister, Deputy Smyth, with regard to e-government generally. Is there yet another layer potentially holding this back? What is the Minister of State doing? Does he have a role? I just do not know.
Seán Crowe (Dublin South West, Sinn Fein)
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I do not wish to delay the meeting but it would be useful to get a written response first. If we decide we need to bring in those officials on the basis of a written response, we certainly should do so.
Martin Conway (Fine Gael)
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Clearly, we should do so if the witnesses are not able to shine any light on the matter.
Róisín Shortall (Dublin North West, Social Democrats)
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In fairness to the witnesses, it has to be said that they are operating within a context in which they are seriously constrained in what they can do. I know we are giving them a grilling today but the whole thing is just so frustrating. It is important we get to the root of the problem because we will not make progress on integrated healthcare otherwise.
Seán Crowe (Dublin South West, Sinn Fein)
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That is agreed.
Martin Conway (Fine Gael)
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We should also write to the Minister to get his take on this. At the time, did the then Minister approve of the decision and was there any pushback against the Department of Public Expenditure and Reform? We need an analysis from the Minister.
Seán Crowe (Dublin South West, Sinn Fein)
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I will move on.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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The individual health identifier was widely used during the pandemic. Since the pandemic, how much is this identifier being used in everyday health settings?
Mr. Fran Thompson:
It is beginning to be used in healthcare settings. The biggest challenge we have faced with the individual health identifier, IHI, was not the overall index; it was the population of that index into individual solutions. Part of the challenge is to make sure we absolutely uniquely identify the person before we assign him or her an IHI. We have started with some of our big solutions. We are rolling the IHI out to our patient administration systems. We have started in the north west and are working our way down the country. We are approximately 36% of the way there in Letterkenny University Hospital; 58% of the way there in the Saolta University Health Care Group; 72% of the way there in Dublin Midlands Hospital Group; and approximately 75% of the way there in the Ireland East Hospital Group. We have also rolled it out into other areas such as the primary care reimbursement service, PCRS, health screening, Covid and GP practices. We are rolling it out to any message that goes across our health link bus. We have seen approximately 30 million messages through our health link bus. This allows us to communicate between primary care, GPs and acute hospitals. We will take those messages and put the IHI into them. We are rolling the IHI out quite considerably. In addition, we utilise it within our data lake when we are bringing data together. We can aggregate those data to try to get views of patients across the totality of the solutions.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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How long will it take to roll out this programme?
Mr. Fran Thompson:
There will always be new systems and things that will need the IHI. The rationale for rolling it into the patient administration system in hospitals is that those systems are the front door to a hospital and spread those data to other systems from there. All the other clinical systems would then have the IHI as well. Our goal this year is to establish the IHI as the primary utilisation. I am aware that one of the asks in the health information Bill is that the IHI and personal public service number, PPSN, be utilised. Due to the way we have configured the solution, we can make that swap very simply.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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There is the substantial issue of the extent to which Irish hospitals are digitised with regard to their paper base. I am pretty taken aback by the answer. Professor Martin Curley of Maynooth University reckons that 85% of all Irish hospitals remain paper based. Is that correct?
Mr. Fran Thompson:
There are substantial point solutions in our Irish hospitals. Our laboratories and patient administration systems are digitised. Our radiology systems are fully digitised. They account for a considerable amount of traffic. There are also many point clinical solutions but the core medical record is not digitised, except in the areas where we have deployed electronic healthcare records, that is, St. James's Hospital and the four maternity hospitals we have spoken about.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Professor Curley is correct that 85% of hospitals are still-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It is definitely north of 50%. Professor Curley says it is 85% so the figure is somewhere in between.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I presume it will take a long time to make the change to digitisation.
Dr. Brendan Murphy:
It is not simple, even on the four sites of the maternity hospitals or St. James's Hospital. Changing to an electronic health record has been one of the biggest changes in my professional working life because it impacts on each and every way we work throughout the healthcare team. It comes with vast advantages and improvements but a heavy investment in time, resources and training to ensure it is done carefully and continued and optimised even after the solution goes in. The solution is a combination of people and process, as well as the technology.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Obviously, digitisation can be done. It has been done in other jurisdictions.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Yes, we are doing it but we are way behind. Considering Ireland has all these IT companies-----
Dr. Brendan Murphy:
There are well recognised international examples of where this has been done and failed. I keep coming back to my being the clinician at the table. These are clinical projects that are digitally enabled. The change needs to be from the front-line end users. Otherwise, it will be an expensive piece of kit that is left lying. I have been in ivory tower academic centres in the United States where the residents had their backs to the computers, with paper still in their hands. These were some of what were meant to be the ivory towers and the best centres. To be successful, we need to engage clinician teams from the ground up in order that they see it is for their benefit. Most of us go to work for the benefit of the patient, first and foremost. The patient teams need to see this is a patient care and safety issue that also makes their healthcare provision more efficient and easier. In some ways, it takes time and gives it back to the care.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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There are obviously huge advantages for efficiency in digitalisation but there are also possible pitfalls.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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What pitfalls?
Dr. Brendan Murphy:
I can give an example of our own. This is why there were questions about downtime and unexpected attacks. One has to build in contingency. In healthcare, it is almost like trying to put in place a solution when the train is careering down the track. We have to put in place solutions that work for the end-user but, at the same time, they have to be safe and effective, with backup plans and contingency plans for business as usual and for downtimes. We try to mitigate the risk. I happen to be the clinical risk manager, as well as the clinical neonatologist for the maternity and newborn. We have to put in risk mitigation to try to reduce the risk of harm. We try to foresee the "known unknowns" as well as, to paraphrase another committee member in the United States, the "unknown unknowns". None of us ever envisaged a complete cyberattack on our complete healthcare system. Yet, even during that awful time, we had in place the beginnings of a 24-7 system where we could at least get the immediate information available to hand in order to continue to provide care. It took us several weeks to recover, build our systems back up and try to mitigate the risk for the patients-----
Mr. Fran Thompson:
I will add one point. There have been well-documented international challenges and disasters, if we can put it that way, with electronic healthcare records. The reason ours have been successful is we have taken some lessons that we have learned there. Much of that is around having a really strong clinical lead and clinical leadership from the very beginning of the programme. We make sure that on the electronic health records, EHR, team there are clinical specialists from all sorts of areas, such as nursing and other specialities within the hospital. We then design, validate, test and deliver the solution set with their colleagues. As Dr. Murphy said, the IT people really are an enabler for that and for making sure that it happens successfully. Ultimately, these are clinically led, clinically delivered programmes of work. They are the ones that have been successful. We can see it even in the tactical solutions we have deployed where we have that clinical leadership and clinical guidance oversight. They are the ones that are successful, and they do not end up being a piece of tin sitting in the corner.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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This wonderful technology that we have is a great thing. Yet, regarding patient confidentiality, patient input and patients seeing their medical records, is this a game-changer in the digitisation of medical records? Obviously, what goes on is still basically paper based. Most medical records can now be done in real time, not only for the doctor or the nurse, but also for the patient. Does this change the dynamic of the relationship between doctor, patient and so forth in relation to digitisation?
Dr. Brendan Murphy:
In both primary care and the acute setting, this is where some systems have failed because the system needs to be designed so that the healthcare professional is not spending all their time at the computer, instead of with the patient. That has certainly been a criticism in North America. I am sure we have all read about that. What we have tried to do is to design systems that enable real-time documentation. I can give the example of the neo-natal intensive care, where nursing staff are documenting and using the systems to take the measurements from the monitors and the ventilators in real time, and are validating them, as opposed to having to manually transcribe. The data is probably more accurate, more structured for interrogation later and it also takes time away from manual transcription for the nursing staff. We worked out that nursing staff were saving in the region of 45 minutes per shift, which translates over time. More strongly than that, our nursing staff love it because it frees them up to deal with their patient at the bedside, and also, they get home on time. They are not spending an hour at the end of their shift retrospectively writing notes.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Forty-five minutes for a shift is impressive.
Dr. Brendan Murphy:
It is per patient or thereabouts in that example. The strongest example of that - not to hog the microphone - relates to our junior medical staff who move and rotate between hospitals. I can now say this of myself because I moved to University Hospital Waterford, where we are paper based. We missed the electronic record when it went down. There were people who had an aversion to using a computer at the outset and needed to be coaxed and changed. In every project, there are early innovators and laggards, but even those people were saying, “I never thought I would say this but”, because of the efficiency, the freedom and the access. It is not perfect, and we still need to optimise it. It is a living system that still has input. Even then, with a national system, we need careful governance. We take the ideas in and assess them to ensure that my good idea does not impact elsewhere. We mitigate risk. It is working well.
Seán Crowe (Dublin South West, Sinn Fein)
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I am conscious that we are finishing at 11.20 a.m. If I do not get members in, I will bring those members in first for the next round of speakers. I call Senator Conway.
Martin Conway (Fine Gael)
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I have a couple of quick questions. How much in total did the cyberattack cost the HSE?
Martin Conway (Fine Gael)
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That was obviously delayed because the €88 million had to be spent. There were 48,000 queries or issues. Most of them, thankfully, were benign, but they had to investigate 1,200. What was the cost in the investigation of those 1,200 and was any patient’s data breached? If so, were those patients informed?
Mr. Fran Thompson:
No patient data was breached in any of those. An investigation just means that we are running a formal investigation and our response is immediate to be able to say, “There is an alert that has been raised and now we need to do something around that.” We might actually take a device or an application off the system and make sure that there are no issues with that. We also have additional technology that stops any data being infiltrated or taken out of the HSE. We close those investigations that we run after a period of time. The cost to us to run those is embedded, so that is part of what the 23 staff are doing in conjunction with our external supports.
Martin Conway (Fine Gael)
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Is it the case that there are 23 staff working full-time on dealing with these breaches of concern?
Martin Conway (Fine Gael)
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Sure. How much money is the HSE spending on outside resources?
Mr. Michael Redmond:
We have what is called a security operations centre, which is largely sourced from external expertise in technology and providers. That cost €4.5 million in 2022. It is likely to rise in 2023. We are out to procurement on that at the moment, so I cannot give the Senator a figure on it.
Martin Conway (Fine Gael)
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Finally on cybersecurity, how much did the HSE spend on outside experts during the big cybersecurity attack?
Martin Conway (Fine Gael)
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I will just go on to the situation. I think we here are all very taken aback at the lack of progress, to say the least, regarding the commitments in the 2020 programme for Government. Clearly, it is black and white.
Three years into the present Government, commitments concerning e-health in the programme for Government are not being met. This is a political issue and an issue for the HSE. I accept that the HSE has a vision, which was outlined in the opening statement. I suggest that there is no plan to back up that vision. We all have mission statements, but you must have a plan to implement that. Does the HSE not have a plan because it is getting pushback from the Department of Public Expenditure and Reform? Is the HSE not getting the support it needs from the Department of Health or the Minister? Are those reasons the HSE does not have the plan? It seems to be piecemeal tactical and targeted measures with no overall knitted-together plan. While there is a vision, there is no plan.
Mr. Michael Redmond:
I thank the Senator. We do not have a plan to deliver the master plan for the electronic health record because we do not have approval for that. We have pivoted to deliver those tactical solutions. Some are brilliant but they are tactical. We publish the e-health and ICT capital plan every year around those solutions. This year's plan is investing €140 million in total, approximately €110 million of which will be directly on digital transformation solutions. These tactical solutions are either in a facility or a particular discipline. We publish the plan every year.
Martin Conway (Fine Gael)
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The HSE publishes a plan but of the plans that have been published, taking the cyberattack and Covid-19 out, none of the HSE's plans has been delivered since 2015, neither the yearly plan nor the HSE's overarching plan. There have been no deliverables in any real, tangible sense that will make a difference in creating an e-health system in this country.
Martin Conway (Fine Gael)
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As Deputy Shortall pointed out, there are examples of good practice but they are few and far between. Take the plan published in 2015, which involved a costing of €900 million. Does Mr. Thompson agree that 90% of that plan has not been delivered?
Martin Conway (Fine Gael)
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It is like reading a book with a few good chapters but the book overall may not be good. In this situation, 90% of what was envisaged in the 2015 plan has not really been delivered, which is an outrageous indictment of the entire HSE organisation. The HSE is in a situation where a plan was published, which was not destined to end up on a shelf for any particular reason, but would make a difference to the lives of the citizens of this country, and ultimately, save lives. However, 90% of this plan has not been delivered. Does Mr. Thompson agree?
Mr. Fran Thompson:
We have been able to deliver on a range of tactical solutions which have made a difference in a range of areas, both in community and hospitals. For example, I spoke about e-referrals. Most referrals are now sent electronically from GPs to hospitals. We have delivered a range of solutions and systems which are making a difference and providing safer and better healthcare. However, we did not get past the starting line with the EHR.
Martin Conway (Fine Gael)
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Martin Curley stepped down. Who is acting in his role now?
Annie Hoey (Labour)
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Are patients, patient advocates or people with real lived experience on the e-health committee? I am not sure if it is quite an advisory committee. Are they involved in this process? How much are actual current patients involved in this process in terms of their own experiences? Have the delays to this cost lives? I do not mean that in an inflammatory way. I can talk personally, as I am sure anyone in the Chamber may, about people not being able to find files, things not happening and delays. Is there a concern that as technology is moving on in other countries, we are falling behind in our patient responsibilities and patient care?
Mr. Fran Thompson:
There is a representative from the Irish Platform for Patient Organisations, Science and Industry, IPPOSI, on the HSE technology and transformation board committee. It is a decision-making part of the HSE. On top of that, when we deploy solutions, we utilise patient groups either in that area or more widely as part of that deployment. I will refer the second question to my colleague, Dr. Murphy.
Seán Crowe (Dublin South West, Sinn Fein)
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In the opening statement, it was stated that 400 people are working in the IT system in the HSE.
Seán Crowe (Dublin South West, Sinn Fein)
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How many are working in the system?
Seán Crowe (Dublin South West, Sinn Fein)
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The HSE had a workforce of 156,000 in December. Is there a gross under-representation of IT support?
Mr. Fran Thompson:
We have grown that from a historically low basis. You cannot take in lots of IT people in one go. They must be gradually brought in because they have to be trained, and they must understand the healthcare system. Within our organisation, there is a crew of people under Mr. Redmond involved in recruiting. We have met our targets in recruitment for the last two years, which is a challenge given the marketplace. We have a good training programme for those people to bring them along. We have to do it in incremental chunks, otherwise we will flood the system.
Seán Crowe (Dublin South West, Sinn Fein)
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A staff of 156,000 seems an awful lot within the system. As someone looking in from the outside, it strikes me that support is under-represented. How many machines in the health service are still running on operating systems past end-of-life support? This came up previously.
Mr. Fran Thompson:
It is less than 5% now. We have done a lot of work. By the end of February, it will be around 2%. Some are cases where people got new devices and hung on to their existing devices to make sure all the data was transferred. Those devices will fall off the system at the end of February.
Seán Crowe (Dublin South West, Sinn Fein)
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I do not understand. Is it 5% or 2%? How many machines are there?
Seán Crowe (Dublin South West, Sinn Fein)
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Does that figure refer to machines running on operating systems past end-of-life support?
Seán Crowe (Dublin South West, Sinn Fein)
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One of the big challenges is around radiology. There was big concern regarding that. Are those machines still operating on systems that are ending?
Mr. Fran Thompson:
The NIMIS core system was upgraded hugely last year to NIMIS 2.0 and is now functioning well. Many of the front-end devices have been changed. Some radiology system devices are being changed as we go through. They are also fully supported by the vendor, which has back-to-back arrangements with Microsoft.
Róisín Shortall (Dublin North West, Social Democrats)
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Regarding delays in funding approvals, is that mainly on the capital side as opposed to the current side or staffing, etc.? Is it capital approval that is required?
Róisín Shortall (Dublin North West, Social Democrats)
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Yes.
Róisín Shortall (Dublin North West, Social Democrats)
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Can Mr. Thomson send us the figures for capital and staffing on what is required to kick-start the programme?
Seán Crowe (Dublin South West, Sinn Fein)
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I apologise to anyone who did not get an opportunity to comment such as Senator Kyne who has been here since the beginning of the meeting.
I thank the representatives of the HSE for providing assistance on this important matter to the committee. The debate has been useful and I thank them for their engagement. This debate has been very insightful and we got a sense of the challenges that are faced by the organisations and the system. I am sure that we would all have a lot more questions if we had more time. I will suspend the meeting for a few minutes to bring in our next guest.
Seán Crowe (Dublin South West, Sinn Fein)
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I welcome Dr. Avril Kennan, CEO, Ms Suzanne McCormack, chair, and CEO of the Irish Thoracic Society; and Dr. Mark White, vice president for research, innovation and graduate studies in SETU Waterford, from Health Research Charities Ireland. I invite Dr. Kennan to make her opening remarks.
Dr. Avril Kennan:
I thank the committee for the opportunity to speak today about electronic records in healthcare and related issues. I am the CEO of HRCI, the national umbrella body for charities in Ireland, who are improving lives through health, medical and social care research. I am accompanied today by our chair, Ms Suzanne McCormack, and the chair of the Irish Health Research Forum, Dr. Mark White.
The main message I want to impart today is that electronic health records are essential, not just for healthcare, but also for research. I want to start by telling a story. There is a woman who lives in the midlands, who is getting older but who is definitely not old. She is full of life, has a fabulous pixie cut, is planning on getting back to dancing after a Covid-enforced break and, once, despite no official training as a chef, won an award for running one of the best restaurants in the world. She is busy with her children and many grandchildren, and she is also very busy managing her health. She, like many, has a complicated medical history. She has severe allergies to many foods as well as most antibiotics. She has a rare condition of the adrenal glands and has some lung damage from a lifetime of asthma. When she first meets a healthcare professional, she has many things to explain but explain she must because her health records are filed with her GP on paper, in different departments in two separate hospitals, more recently with an online doctor, and also in her handbag. There is no centralised record of her complicated medical history that either she or her doctors and nurses can access. Her all too regular rushes to the emergency department result in repeated and long-winded explanations about her medical history and require her to be well enough to impart that information. During her most recent admission, she was not allowed to have anyone accompany her and, as she was very weak at the time, she handed her phone to a nurse and asked her to read her own curated medical notes. She has essentially created her own electronic health record, but it is nowhere except on her phone and so all the rich data about her rare and unusual symptoms are lost to medical research. Her rare condition could have been prevented through better medical management and yet, without capturing her health data digitally, what she has gone through can never be used to ensure future patients do not go through the same thing. I tell this story because I know members will relate to it, whether through their own experiences or those of family and friends. I work with and represent more than 40 charities that, in turn, represent, and work on behalf of more than 1 million patients in Ireland, all of whom have similar stories.
While many of our member organisations provide patient services, they come to us because they are also focused on improving lives through research. They fund research, support patient and public involvement in it, work to ensure that research is meaningful to the people they represent and strive to ensure that its outcomes truly make a difference in people's lives. They understand that research is the healthcare of tomorrow and know that not enabling research in all aspects of healthcare is like doing the weekly shop but only buying enough food to last two days. They are an essential part of the health research ecosystem in Ireland.
To give a sense of who the health research charities are, those that are represented on our board, because HRCI is itself a charity, are the Alpha 1 Foundation, the Central Remedial Clinic, Cystic Fibrosis Ireland, DEBRA Ireland, the Irish Thoracic Society, the National Children's Research Centre, and the Saint John of God Research Foundation. Our other members represent people with rare diseases, cancer, dementia, heart conditions, mental health issues, many other chronic conditions, and also carers. Together, these charities provide a beautiful example of what research means to people and families and how its impact reaches every family in Ireland.
Today, we launch the 2023 HRCI position paper, entitled Embedding Research in Healthcare, which makes three recommendations to improve health research in Ireland. It is based on the outcomes of Irish Health Research Forum events, which HRCI founded and runs, our ongoing conversations with all stakeholders in the sector and surveys of our member charities. The top priority to strengthen health research in Ireland for our members is the implementation of a national electronic health record. It is, therefore, the first recommendation in our position paper. The other two recommendations, which relate to the need to support genetics and genomics research and the importance of establishing research support functions within the HSE, are also heavily dependent on an electronic health record.
Our members recognise that, as a long-term digital record of a patient's medical history, across different health services, a national electronic health record would facilitate the use of valuable data to improve services and to support research. However, despite pockets of excellence, too many health services are still working in silos and too much valuable data is being lost. We are not alone in calling for electronic health records and there is widespread recognition of their importance. There are strong e-health commitments in the programme for Government, Sláintecare plans and the e-health strategy for Ireland. A recent HIQA report makes a strong case for them, and the 2022 OECD economic survey of Ireland points out Ireland's weakness in digital health and emphasises the need to link existing healthcare datasets.
What is not always discussed however, is the need for a national electronic health record to enable research from the very start. To this end, the research community must be involved in the planning at all stages. Patient involvement is also key, to consider issues around consent and to ensure public trust. Separately, the health information Bill, currently under development, must provide a strong legislative basis to support the so-called secondary use of data - the use of data in research studies and to improve services.
In an example of the power of electronic health records to provide data for research, the information coming out of the UK during the pandemic was critical in the world's efforts to save lives. For example, during the early stages of Covid, researchers analysed 17 million NHS electronic health records. This enabled them to identify the most at-risk populations, ultimately leading to decisions on which groups to prioritise for Covid vaccines.
We are very aware of the enormous cost and challenges involved in implementing a national electronic health record. Media coverage in the past week indicates that the barriers may be very big indeed. Patient involvement is key in this process to overcome resistance where it exists. Patients will not and should not tolerate red tape, inertia, or resistance to change that will improve their lives, and they need to be involved in discussions at every stage and level. From the earliest discussions, the importance of enabling research must be considered. There is no alternative to going digital in healthcare, so it is only a matter of when. It will require bravery and investment, but if we are not taking charge of our own future healthcare then who is. We and our members are working in a myriad of ways to create positive change for patients, their families and carers across Ireland, through research. We ask the committee to work with us to that end. I urge members to stay connected with us and to do whatever is in their gift to implement a national electronic health record. I will leave the committee with one takeaway: in every conversation they have about healthcare, they should ask the question of how research is being enabled. I thank members for their presence and attention today. My colleagues and I welcome any questions. This concludes my opening statement.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Dr. Kennan very much. It was very useful to start off with the example she gave of the woman in the midlands who has her own electronic record. There is another takeaway for people listening at home. If anyone is getting cancer or other treatment, he or she should take a photograph of his or her prescription. It is usually the one thing people are asked about and it is panic stations if they do not know it. It is a simple thing to take a photograph of one's most recent prescription. I call Senator Kyne
Seán Kyne (Fine Gael)
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I welcome Dr. Kennan and the other witnesses. I did not get an opportunity to say it in the first session, but I have often said to the Secretary General of the Department of Health that he is in a unique position given that he was previously Secretary General of the Department of Public Expenditure. It is important to know whether Mr. Watt stands over the refusal in 2018 of the business case to progress the digital agenda in health.
The witnesses sat through the first session. What did Dr. Kennan make of the HSE's responses on this entire area?
Dr. Avril Kennan:
I acknowledge that there is a group of people working very hard in difficult circumstances. I find it a challenge when I think about the fact that there was a business plan so many years ago that has not been implemented.
Not only was the initiative neither approved nor implemented, but there does not seem to have been any further ongoing persistence around that. We need persistence. This is not an issue that can be ignored. I imagine that the topic of electronic records relates to almost every conversation that members have at this forum, and could strengthen any initiatives in healthcare going forward. I would like to see it considered as a more urgent topic.
Dr. Mark White:
It is interesting that the previous session discussed the health service and not the health system. My colleague and I are here to represent Health Research Charities Ireland and the charities sector. I remind members that the health system is made up of a myriad of voluntary statutory providers, including some of the larger hospitals in the country and the charities sector, which we represent here today. My first observation is that any of the solutions that were put forward here today are very health service-centric and not health system-centric. My second observation about this morning, as an outsider, is that longevity in terms of health service improvement was spoken about as part of Sláintecare. One of the strongest chief information officers that this country has ever had was Richard Corbridge, who worked in the health services until 2017. I believe that a lack of engagement and investment acted as a catalyst for him leaving his post in Ireland and returning to the UK as the chief information officer for Boots. He has implemented a number of really innovative programmes of change within the Boots chain in the UK, which are starting to be implemented here in Ireland. Longevity is the big issue.
Seán Kyne (Fine Gael)
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Dr. Kennan mentioned a lady in the midlands. Thankfully, she was in a position to hand over her phone and to give the code of her phone to someone to open it and access her information. That same lady could have been in an accident, maybe unrelated to her incident. If she fell and banged her head, and was unconscious, she would not be in a position to do the very basics. What do the witnesses see as the gold standard in this regard? Is it the case that somebody should be able to voluntarily have a bracelet, a pendant or a chain around his or her neck, if he or she wishes? This would mean that if such a person were in an accident outside of his or her own area and if there were no records available in the local hospital - for example, if the person was from Galway but had an accident in Dublin - his or her information could be voluntarily accessed from the bracelet or pendant. Is that the gold standard for accessing all the information about a person, including any prior health conditions? For example, the person may have suffered a stroke, or may have respiratory issues. Is that the gold standard? If Dr. Kennan were designing this, and it could be designed, how would she see it?
Dr. Avril Kennan:
There are two related elements that we need to see implemented. The first is a unique health identifier, and sometimes it is called an individual health identifier. I mean everybody's unique number. We might persuade the public to wear a bracelet, but almost everyone has a phone or wallet and the number could be present there. It would mean that if a person were unconscious, his or her health data could be found easily. Then, critically, all that data could be linked to a national electronic health record rather than, as we have now, an electronic health record that is just associated with one health service. We need a national one where all of a person's important information can be found no matter where one ends up in hospital.
Seán Kyne (Fine Gael)
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We passed the Health Identifiers Act in 2014. I remember speaking on it at the time. I thought this was the precursor for everything in terms of implementing this.
When I go my local GP or speak to the staff on the phone, I am asked for my name and for my date of birth in case there is confusion, for example if there is somebody with the same name in the area. GP offices have all of a person's health records, including information on recent checks, blood results, cholesterol levels and more. Everything we do is electronically based. I do not know why this matter is so complicated. When a person goes to hospital, the hospital staff should be able to use a simple number to identify him or her. The personal public service number, PPSN, cannot be used because it concerns social protection. We do not have a national identity card. As I understood from the Minister's speech in 2014, information will be required to allow a unique identification number to be provided. I do not see what the great mystery is. We all bank online, use all sorts of codes and avail of security measures. At the very least, when one goes to an emergency department the staff should be able to access one's GP records and vice versa. I am from Galway. If I have an accident in Dublin, health services there should be able to access my information which is held in Galway. I do not know why this kind of linkage cannot be done.
Do other members know their unique identification number? Is it something that is sent out? I do not know my unique number but I know my PPSN, my date of birth and my address. I do not know if my GP or local ED has my unique number. A representative of the first HSE group said that there are 9 million records in a certain part of the HSE and another area has 4 million identifications. Do the officials know how we have gone from the 2014 Act to where we are today?
Seán Kyne (Fine Gael)
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We have the 2014 Act that allows for identification numbers.
Dr. Avril Kennan:
Yes, but the provisions of the Act have not been implemented. We have numbers that are associated with different services but we do not have something at a national level that connects it all together. The mystery for the Senator is also a mystery for our more than 40 member charities because there has been a black box as to why we cannot progress this issue. If we cannot get these basics right, how will we reach the point where we enable very important research?
Ms Suzanne McCormack:
I agree. The unique health identifier and the linkage are key. There are great pockets of good practice and good electronic records in different institutions. It is a fact that they are not linked and data are not optimising research, and the potential for research in terms of being able to identify health inequalities geographically, including areas of good practice that can be applied elsewhere. There is an inability to provide that potential.
Seán Kyne (Fine Gael)
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I assume it would be relatively simple to do this even at a local hospital. My GP is located outside of Galway city. I believe the emergency department or the Saolta Hospital Group in UHG could easily do this through the PPS number or whatever. It has been said that a PPS number cannot be used. Surely with permission from a patient, a PPS number could be used to access records. Simply, one could pilot the scheme within a local group and then expand it nationally. I repeat that everything we do is electronically based. I cannot see how, with all the expertise we have, this connectivity and connection cannot be done.
Dr. Avril Kennan:
I wish to mention a very quick story about a woman in Limerick. I talked to a colleague in Limerick and learned that her 80-year-old mother was in hospital during the week. Both of them watched a man cart piles of patient paper records from one end of the hospital to the other. Her mother asked why they would not just use computers. This is really what it is all about. It is hard to fathom that we have not made more progress yet. In Europe, people are now talking about a health data space. Ireland will have to get on board with that. We are already behind. It is only a matter of when. It absolutely has to happen. I encourage all of the members to keep this issue on the agenda. Ongoing pressure will be needed. I urge members to bring this issue into the conversation whenever they can.
Dr. Mark White:
There are pockets of innovation. At the previous session we were led to believe that Ireland's best brains in terms of health service IT were in the room. I could not get an answer to the question that the Senator has just asked us as representatives of the charity sector.
There are pockets of innovation that have not translated into mainstream health service provision. There are many good ideas out there. A health passport for intellectual disability clients has been rolled out throughout the north west. As members can imagine, hospitalising a client or other person with an intellectual disability can be a very upsetting and difficult situation for the families and carers. A health passport system has been operating for the past four to five years in the north west. It could easily be translated throughout the country and would make a big difference to the lives of people with an intellectual disability who find themselves in a health crisis.
I reiterate the point made by Dr. Kennan that data are everything, particularly when it comes to research. We need joined-up data. People think of health service research as being experiments in laboratories. The vast majority of health service research done in the UK and elsewhere in Europe is actually done on data. When one has real data that are meaningful and a full version of the truth, one can uncover the health services, the therapeutics and the world of tomorrow when it comes to health service provision.
David Cullinane (Waterford, Sinn Fein)
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I welcome Dr. Kennan and her colleagues. There is real frustration that we have been discussing these issues for the best part of ten years, and possibly longer. As was outlined, there have been numerous reports advocating changes in this area, such as in respect of the use of unique patient identifiers, electronic patient records and better integrating IT systems across healthcare for all the reasons the witnesses have outlined. We have to call out where the failure lies and that is a political failure. If a Minister does not drive this - there is no policy priority coming from this Minister and, I would argue, successive Ministers - we will fall behind. We are light years away from where we need to be. We have to keep putting the spotlight on this issue. In the context of the witnesses' ask of the committee, the members of which operate in the health space on a continuous basis and are involved in many different debates, this is front and centre in terms of many of those issues.
Dr. Kennan gave a human example earlier. From our perspective as Oireachtas Members, we can give examples of the frustration of being unable to access data and the reasons we are given for that. We regularly table parliamentary questions seeking data and one of the responses we often receive is that the system does not capture the data. Another is that as there are multiple systems operating across different elements of the health service and those systems are not aligned, it is not possible to provide the data a Deputy is seeking. That is what we get back in response to many parliamentary questions seeking even basic data.
I refer to an important and fundamental point that was made. Dr. White may wish to take this one. Dr. Kennan referred to the need for a national electronic health record to enable research from the very start. If we do not have that, we are not enabling research from the get-go simply because we do not have the systems to capture it. I ask Dr. White to outline, from a research perspective first, the added value having these systems in place would bring to his work and that of his colleagues.
Dr. Mark White:
I thank the Deputy. The fact is that we only have pockets of data. Many researchers in Ireland, when they seek to look at a national picture, receive the same answers the Deputy receives to his parliamentary questions. It is very important for researchers to have access to national data. In the world of research, it is very difficult to prove or disprove something when one just has small or regional cohorts. What is needed is generalisability. One wants to be able to say a nation's health is affected by X, Y or Z. Having those joined-up data is very important because on publication of one's little pocket of data, the first criticism that comes from the scientific community in Europe and across the globe is that it is an interesting finding but it only happened in the south east of Ireland, within a private patient cohort or in a small cohort in the west of Ireland. Generalising the scientific findings of any research is very difficult without having these national databases and national access to people's records and health. It has an impact on us as European partners but it also has an impact on the scientific community across the globe.
David Cullinane (Waterford, Sinn Fein)
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In the previous session, we heard directly from the HSE. The missing link in all of this is the Department of Health, which has questions to answer as well. It certainly has questions to answer in respect of the business case we discussed earlier. I have engaged with senior representatives in the Department on this issue of integrating IT systems and rolling out unique patient identifiers and electronic patient records. We know that hospitals operate on different systems. I have experience in the area of disabilities, where, for example, children's disability network teams are operating from software for which the company cannot provide an update, which means they have to build an entirely new system. We have all these examples of failures, systems not working, different hospitals working to different systems and so on. We know all the difficulties that flags up. When I spoke to the Department on this, the fundamental question was whether to go for a single integrated system or, alternatively, interoperability, which is where there are different systems but they can speak to each other. Is that something with which the witnesses have grappled in terms of their research and consideration of this? Obviously, there is a cost. If it is a single system, it could be a single point of failure. We want to get to a place where systems are aligned as best we can. In the context of that clash, have the witnesses considered whether we should go for a single IT system across the health services that integrates all those multiple systems or is it more about interoperability?
Dr. Avril Kennan:
In some ways, it is not our place to speak to technical solutions. There are many people out there who can answer those questions. What we can say, however, is that this is being done across the world, so there are technical solutions. The advantage of being a bit behind, as we are in Ireland, is that we can look to those other examples and not make the same mistakes that others have made. Ms McCormack and I have experience of working with patient registries, which are another really important part of this picture. She may wish to speak to that. Interoperability is the key in that regard. It is about allowing centres to hold onto their own data and keep them safe but, through trusted third parties and safe havens, having the ability to bring those data together to be analysed by researchers. The key thing is that, regardless of how we do it - that is just the technical side and there are always solutions - it is about the willingness to get on board. As Dr. White stated, there will be a difficult time ahead when the paper records have to be put online. That will create a significant amount of work but it has to happen and people have to get on board with it.
David Cullinane (Waterford, Sinn Fein)
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I suspect that the time horizon of a Minister for Health might be a little different from how many of these projects are delivered. We have to be brave when we look at this, however. Some of these measures require medium- to long-term investment and will take time to bed in before there is an outcome, but they are really important. I know Ms McCormack wishes to come in but my time is limited.
The final point I wish to raise relates to the point in Dr. Kennan's opening statement about the health services operating in siloes in the absence of having integrated systems and so on. That is certainly an issue in respect of which we have a concern. Sláintecare was meant to integrate health services operationally and to join up community health organisations and hospital groups within a single structure, with single tiers of management in respect of primary, community and acute services so that we can start prioritising healthcare based on need and using resources in the most effective way.
As we move into regional health areas and start to integrate structurally our health services, if we do not have the IT systems that join it up or a greater use of unique patient identifiers and electronic paper records, we are not going to get the bang for buck we need. That is as crucial as the realignment of the structures. I ask the witnesses to elaborate on the issue of silos and what was meant from their perspective.
Dr. Avril Kennan:
What was meant from our perspective is just what the Deputy is talking about. GPs are operating off one system and each hospital operates off another system. Even in departments within hospitals staff have to transfer paper records down a corridor and that does not always happen in a timely fashion. It delays everything. That is what we were talking about. As Dr. White said, that is not just important from a healthcare perspective; it is critical from a research perspective. People talk now about data being the new oil. In Ireland, we had an isolated genetic population over many years. Thankfully, there is more diversity now but it is a rich data source to mine for differences in genetics. The differences in genes that cause disease pop out from the background. There is so much potential in bringing it all together. That is what we were talking about in terms of silos.
Ms Suzanne McCormack:
On the registry aspect, it is a good example of where health records and data are being used well for specific diseases. We have good registries for cystic fibrosis and the National Cancer Registry. We run one for interstitial lung disease, ILD. There are many more smaller ones, which are very powerful. The capacity to link those to other data sets is a missed opportunity. If that were possible, there is so much more that could be done. We also know from the patients who provide the data for these registries how invested they are. It is not a question of resistance to giving their data, because they are very happy to do it, but they also have expectations around how those data are used and they feel very strongly about that. That comes out again and again in our meetings and through our representatives.
David Cullinane (Waterford, Sinn Fein)
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I thank the witnesses for their work and give them my best wishes.
Róisín Shortall (Dublin North West, Social Democrats)
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The witnesses are welcome. I thank them for coming in. I agree that we have to have the Secretary General of the Department of Health before us to answer for both what that Department is doing and for the position the Department of Public Expenditure and Reform took in 2018. We should aim to do that soon because this is so fundamental to everything else in the health service. The Chair suggested asking the Department of Public Expenditure and Reform for a written response. I propose that we also ask officials to send us a copy of the 2018 letter with its response to the strategy. Reference was made to Richard Corbridge. I remember him well from the health service. He was regarded as quite exceptional in terms of his vision for the future and the need to digitalise the entire health service. He was largely responsible for drawing up that 2015 strategy. Regrettably, after the response from the Department of Public Expenditure and Reform, he just decided to walk away because it was quite clear there was no appetite for this at either a political level or within the two Departments. Nobody was serious about this. We are seeing this over and over again. We saw it just last year when Laura Magahy and Professor Tom Keane walked away because there was no will to modernise the health service or to do those blindingly obvious things that need to be done. Why are they being blocked? We have to get to the root of that. It is no surprise that Richard Corbridge is now in a very senior role with Boots. He had fantastic ability and it is an utter shame that he was driven out of the health service.
As has been referenced, we have to have data-driven policy and decision-making within the health service. We all know the difficulty in accessing data through parliamentary questions. Even when I was in the Department of Health for a short period, I wanted to know where the health and social care staff were, how many we had and where they were employed. It took four or five months for the HSE to be able to give me those data about its own employees. That is the level of need. It is so completely basic. We know nothing about the prevalence of disease around the country and whether there are particular pockets or anything like that. It is fundamental stuff. The idea of the RHAs is that decisions would be taken on the allocation of budgets based on local need within each of those areas but we do not have those data on local need. It takes forever to get any kind of basic profile of different areas. This is critical. The other thing about that is not only having needs-based budget allocation but having accountability for performance. How can that be done unless what the needs are and what the response is can be measured? There is no accountability right down through the system because we cannot measure these basic things. The witnesses have strong support from the committee. We are keen to accelerate those fundamental reforms or at least get them moving.
I ask them to fill us in from a research perspective. We know the huge benefits for patients of an EHR and all the other aspects of that. From a research perspective, what are the huge obstacles to carrying out meaningful research and the data gaps that are there? Maybe they could fill us in on some of those key areas that they cannot properly do because of the lack of data.
Dr. Mark White:
It starts at the very beginning. I mentioned earlier that we need to approach this from a health system perspective. Even the plans for the RHAs are very health service-centric and not health system-centric. A perfect example is that any researcher in Ireland who wants to undertake any piece of health service research must start with ethics approval, that is, confirmation that the study they have proposed to undertake is ethical. The health system in Ireland does not have an ethics approval system. We work through the HSE and it is more than happy to provide ethics approval and ethics support for our own heath services but when you look outside the health services and into the health charities, GP populations or primary care, it becomes a foggy and grey area even just getting the authority to conduct a study. It starts at the very beginning and it then goes through. For example, if someone wanted to look at a cohort in the intellectual disability services in Ireland, the first question would be whether they are looking at the statutory patients, the voluntary patients who are in our voluntary services or the clients and patients who are supported by our charity partners. It is very difficult to capture the population that person wants to start their study at because of the disparate nature of the services we provide in Ireland. The one way of connecting that is through an electronic record or passport where, at the click of a button they could identify the cohort they want to study. If there was an electronic ethics submission for the country, they could then submit an electronic submission into a national ethics committee that would cover all sectors, not just statutory, and would not differentiate between the statutory, voluntary and primary systems. Those types of systems would enable a lot more research.
The second thing is that we tend to do a lot of inpatient or on-patient trials and research. Other countries do those but not to the same extent because they have access to the data. An awful lot of desk-type research can be done and an awful lot more modelling could be done if we had access to systems that were system-wide and not just based in the health service, for example.
It would open the doors to all types and genres of research and, more important, it would allow other European countries to come in and examine our data to see how we compare to the European averages and norms, especially when it comes to disease management. Rather than even research, it would help audit why one area uses X type of antibiotic more than other as we do not have that data, or why certain practitioners or specialists use X kind of product in the health service. We could look at the outcomes of patients and why X amount of patients survive in one region and not in another, for example. Without access to the primary data and a system-wide approach, we are going to continue in this quagmire for many years and, as Deputy Cullinane has said, fall way behind the European trajectory in this direction.
Dr. Avril Kennan:
As a short specific example, we launch a position paper today that calls for electronic health records but also for the progression of genetics and genomics research in Ireland. In a good news story, a new strategy was launched in December 2022 on genetics and genomics in Ireland with a strong focus on the issues we like to talk about such as research and patient involvement. What we would ultimately love to see come out of that is an Irish genome project where we would bring together the genome, which is the study of the full genetics of a person or a population----
Róisín Shortall (Dublin North West, Social Democrats)
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I take it that is an Irish public project.
Róisín Shortall (Dublin North West, Social Democrats)
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So that genetic material is not sold off.
Dr. Avril Kennan:
It would open the door to private investment but in a way that was very controlled and where patient needs were front and centre and data was protected. We could technically do that and there is the basis there for it already but if we are not able to link that big data to clinical records, then it is really not worth that much. That is just another example of why an electronic health record is important so we can bring information together for real insight into the Irish population and with a view to future therapies and treatments.
Seán Crowe (Dublin South West, Sinn Fein)
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Does Dr. McCormack have anything to add?
Neasa Hourigan (Dublin Central, Green Party)
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I welcome the witnesses. I know they were probably listening to the first session. To what degree were they aware of the hold-up on electronic healthcare records?
Dr. Avril Kennan:
I was not aware on the specifics. We were aware that things have not progressed but I was not aware of the specifics as to why and to the best of my knowledge, most of our member charities are not aware of this either. That in itself is an issue. We need to be part of the conversation.
Neasa Hourigan (Dublin Central, Green Party)
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Was Dr. Kennan aware that there is no current and updated business case for that issue?
Neasa Hourigan (Dublin Central, Green Party)
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Was Dr. Kennan aware that the business case is linked to the children's hospital?
Neasa Hourigan (Dublin Central, Green Party)
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Okay. That is important because when looking through parliamentary questions, any of us who are asking about the electronic records instantly gets an answer that mentions the children's hospital and the newborn programmes but does not explicitly say the roll-out across the whole system is based on the performance of those things. Does Dr. Kennan have a concern around that?
Dr. Avril Kennan:
I have a big concern. There is back and forth and we want to make sure we do this properly. The worst thing would be to do it in a way that causes more harm than good. I understand the need for lots of discussion and consideration of different models, of international practice and the plans the EU have, but I am very concerned about the timeframes, how long that has just been sitting there without progress, that the original business plan was not reworked in some way or revisited and that there were no discussions on a national level about the hold-ups.
Neasa Hourigan (Dublin Central, Green Party)
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I am aware the witnesses are not experts in this particular area and it is centred more around the data, considering what we have heard this morning, what would they expect to see in terms of this being up and running in Ireland? We are not even at business case stage. Are we years away from a working electronic healthcare system? Is that correct?
Neasa Hourigan (Dublin Central, Green Party)
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As I said to our previous witnesses, I had questions on the operation of data collection, particularly for research and obviously selfishly for our own purposes, the issue around evidence-based design and having that data comes up every week. I want to touch on a number of areas if the business case was happening and if we were at that point. There is an assumption, certainly when we talk to the HSE around this, that it is just the tech system but I want to touch on the staffing and the training aspect and the load that will place on the HSE. For example, I am aware that sometimes there are outpatient clinics with a specialist or nurse practitioner or somebody who then has no administration support. If we are going to do electronic data correctly, we have to input the data to begin with. Can the witnesses outline what they think the load will be across the health system? Will we need additional administration staff or people who are assigned to particular clinics or hospital departments who are tasked with data collection in a particular way and will there be a requirement to roll out training across the board for all front line staff? I read an interesting paper around ethnic research and training people to ask the right questions in a way they were comfortable with and that did not offend the person who was being asked the question. Can they talk a little bit about that and what the load might be in terms of staffing? We may need to see an increase in staffing specifically for correct data collection.
Dr. Avril Kennan:
I will speak to that question for a moment and then will pass it to Dr. White. I acknowledge from work that I am very familiar with in patient registry, there is generally some short-term pain for long-term gain. We have to be really mindful of our health service staff. They are already under far too much pressure and so that side of it will need to be resourced as well. We heard in this morning's session that in the longer term, health service staff really value things going digital. It is going to make their lives easier in the long run. It is not exactly what the Deputy is asking but another part we have to think about is the conversations with patients very early on in terms of their consent to the whole process, in particularly coming from our perspective, capturing their consent around research. I will hand over to Dr. White to say a bit more on that.
Dr. Mark White:
Just for the record, I was aware of some of the issues due to my position in the HSE before leaving it to work in academia.
Neasa Hourigan (Dublin Central, Green Party)
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Okay.
Neasa Hourigan (Dublin Central, Green Party)
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That does not count. That is not official knowledge.
Neasa Hourigan (Dublin Central, Green Party)
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Really what I was asking is had the HSE communicated officially to section 38 and 39 organisations particularly.
Dr. Mark White:
To answer the Deputy's question, there will be a staffing load as we transition. The big question for the system is whether we should we have started this eight or nine years ago when we suggested we should have so that the load and the cost would have been less. That is the bigger question. This is change. Most of the health and public services have had various pay claims based on change and transformation so the platform is set. The number of public servants who embraced technology and digitalisation and pivoted quickly during the pandemic demonstrates that this can be done. This goes back to the original question about the end user. It is difficult for me to explain to my elderly father how he can insure his car, book his national car test, go to see my brother in Spain, all on his phone but that he has ring and sit for 25 minutes on the phone trying to book an appointment in the outpatients department. The end user is absolutely key and that is the catalyst for change for the health service and all health service personnel.
Neasa Hourigan (Dublin Central, Green Party)
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I want to return to the patient interaction with this and understand whether there has been any information or interaction with the data commissioner or the Data Protection Commission office on both research in general and genomics in particular but also on that health information Bill. Is that anything the witnesses are aware of?
Neasa Hourigan (Dublin Central, Green Party)
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Does Dr. Kennan expect to have further interaction as this rolls out?
Dr. Avril Kennan:
It is important that we have discussions with the players that are going to be making decisions around this. We would really welcome that. We are not just here to complain, we can also offer some solutions. Through our member organisations we represent a large portion of the population. Our member organisations are very informed and engaged in these topics and want to see progress. We keep hearing about these barriers and it is really hard to understand what exactly they are and who they are coming from. We must remember that if we involve patients themselves in these conversations it becomes very had to defend positions that are not in the patient's best interest. I have seen it so many times that if a patient is in the room, it changes the whole conversation. That is the kind of thing we would like to see and it is the kind of thing we can help with. We would like to have conversations with any of the stakeholders involved in this.
Neasa Hourigan (Dublin Central, Green Party)
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A more transparent process is what Dr. Kennan is suggesting; it sounds kind of like a forum. Can we return quickly to her description of the health data space in the EU or Europe more generally? I am thinking of genetics because so many other countries are doing better in that regard. I have a particular interest in that area. We have talked a lot this morning about sharing information between institutions, how we do that safely and comprehensively. Are we starting to see a space in Europe where countries are sharing specific data in real time in the longer term, in terms of research? How would we go about facilitating that? Do we believe we need different or additional legislation to make that happen?
Dr. Avril Kennan:
I will ask my colleagues to think about the legislation aspect. As of last year, Europe has been discussing a health data space across all the member states, which is very exciting and ambitious. It is going to help with things like cross-border healthcare. For example, if a patient is on holidays and needs to fill a prescription, he or she will be able to use a personal, unique number to get the prescription in Spain, France or wherever. The discussion is also very mindful of research. As the Deputy mentioned, it is about enabling research across borders. We need to think about that from the start. In order for Ireland to be really part of that, we have to have our own house in order.
Neasa Hourigan (Dublin Central, Green Party)
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They also have to align with EU systems.
Neasa Hourigan (Dublin Central, Green Party)
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We cannot just develop a system domestically; it has to be able to talk to those systems, not between hospitals but also between cities and other countries.
Neasa Hourigan (Dublin Central, Green Party)
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Other than that we do not do it.
Dr. Mark White:
Yes, that is the problem. We are behind our partners on many of the projects because of the timelines. To get an ethics approval in Ireland, for example, some of our members are involved in clinical trials across Europe, we fall way behind our partners, embarrassingly so, at many of the European meetings. The only thing I can see which has raised its head here in Ireland is export control. The types of data that we are creating and how we control and share them across the world is being raised, not by the Department of Health but by the Department of Trade, Enterprise and Employment. We create and generate an awful lot of knowledge and a lot of commercially sensitive and security-sensitive information, even around genomics. One would not think that would create an issue. The research community in Ireland is really grappling with it at the moment. We have not had any shackles put on us before. We have had very liberal approaches to what we do with our data and commercially sensitive information and how we share it with our partners in Europe. There is a whole new spotlight that has come on that in the last six months and it will continue for the next 18 months while we navigate our way through that. However, I do not see anything in Irish legislation precluding us from stepping up to the plate in Europe and playing our part.
Neasa Hourigan (Dublin Central, Green Party)
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Thanks.
Seán Crowe (Dublin South West, Sinn Fein)
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To follow on in respect of the European element, we have these different systems and we heard this morning how some of them clearly do not talk to each other or share information. Are some of the systems we are operating, say in the west of Ireland or the children's hospital element, be capable of sharing that information? Is it just a matter of tweaking the current systems? If we had the legislation in place would it take a huge amount to change the system?
Seán Crowe (Dublin South West, Sinn Fein)
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Patient identifiers are key here, that is a common thread. Going back to the issue of sharing information, the one bugbear a lot of families have at the moment in the context of Covid, RSV and so on, particularly if someone is elderly but not only then, within the hospital system it is not possible to accompany someone in through the accident and emergency department. There was mention of accessing files and so on. If someone is in a different hospital, for instance if my hospital is the Mater and I end up in St. James's, the systems do not talk to each other even though it is only the other side of the city. That is a big difficulty. If I have surgery, it is nearly impossible to get in touch with the surgery team at the moment. There was recently a case of someone who became ill after surgery. The family were trying to get talking to someone but there is no email address or phone number. They could not get through the system. They are just basic things that are in the system. If people had access to their files, they would be able see where things went right or what an operation did or did not do. It is informing the patient and the individual, which is a key part of this whole debate.
Dr. Avril Kennan:
I totally agree. I was very pleased to hear the HSE at the earlier session talking about a patient portal and the fact that it is on the agenda. Certainly, for our member charities, that is absolutely what they will want to see on behalf of the communities they represent, for people to access to their own data. We talk a lot about self-management but how do I self-manage if I do not have my own test results and so on? I once got an accidental referral to an oncologist. It came in the post and of course it was a Friday evening so I had to sit with that referral to an oncologist for the weekend, wondering was there something my general practitioner had not mentioned to me, because I had no access to my own records.
The other thing about a patient portal is that it opens up the potential for patients to put in their own data, things that are important to them such as measurements around their quality of life. That can really add to the richness of the data for research purposes as well.
Seán Crowe (Dublin South West, Sinn Fein)
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We did not really get an opportunity to talk about the issue of allergies, or people who are on Warfarin, blood thinners so on, and the dangers around that. I have been in a Coroner's Court hearing where it was on the file not to give the patient a particular medicine but it was not adhered to. I would like to think that if there was an electronic system, it would be coming up in red letters that they cannot ignore. It is very difficult for the clinician to know that when there is a file or, as Dr. Kennan suggested, several files. The best person to know what is in the file should be the patient. There is no way a clinician who is dealing with certainly 50 and possible 100 patients a day will be able to go through that file. Even though the clinician is supposed to know everything in it, the patient is the one who has to have it.
It becomes even more important when we consider rare diseases. A huge percentage of the Irish population have a rare disease and, in those cases, they are generally more informed about their condition than their doctor, so it is essential they have all of their own data to hand.
Seán Crowe (Dublin South West, Sinn Fein)
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Unfortunately, we have run out of time. I think everyone sees the logic of having a digitised system. We would all agree that it is good and that we need the system, and so on. The frustrating thing that we heard this morning is that, in some cases, we are actually at the starting line, which is very worrying. I give a commitment that we will return to this. It has been suggested that we try to bring in the Secretary General of the Department of Health and the new CEO. We have a regular slot in that regard and we can possibly focus on that at our next meeting with them and at our regular meetings. It is not the case that the issue is going to go away because we have had one meeting, and we will certainly follow through on that. I thank Dr. Kennan for her time and input on this very important issue.
Unfortunately, I have to adjourn the meeting. Our next meeting is in private session at 4 p.m. next Tuesday, 31 January.