Health Policy September 4, 2019
How to operationalise digital change in the NHS – Lessons from around the globe

By Jason Helgerson - Accountable Care Journal

Health Information Technology (HIT) is a global market that is both fast-growing and huge in scale. Both the public and private sector in countries around the world are investing billions in new tools to enable development and implementation. However, the unfortunate reality is that return on these investments is yet to live up to the hype.

Health and social care providers around the globe continue to struggle with the limited ability to effectively communicate with each other, weak capacity for analytics and data management issues that are vexing and frustrating. HIT and ‘digitisation’ haven’t proved to be the panacea that many hoped for.

I have often argued that we have invested too much in HIT and haven’t spent sufficient time and effort fixing the systems that already exist. This has limited the potential benefits that could have been unlocked from data we already have.

While we can’t change the past, my firm belief is that we need to adopt a fundamentally different delivery system to drive digital transformation and not the reverse. However, we need first to decide how we will change patient and population care and, in turn, design HIT solutions that support the kind of system reform we wish to implement.

When I look back at past spending and HIT efforts, I see arguments made to excuse the limited action taken to address the challenging job of changing how we actually provide care. We have used the lack of HIT funds as an excuse for why we can’t do more to improve patient and population health. This needs to change.

Implementing change in New York

In New York, we sought to avoid repeating these common mistakes when implementing a $8 billion USD overhaul of our state’s healthcare delivery system. The effort, which began in 2014 and is still ongoing, was launched to reduce avoidable hospital admissions, improve the overall quality of care, introduce new models of delivery and overhaul reimbursement systems. The goal was total system reform and integration on a vast scale – for a state with a population of 20 million people. Key to our thinking was that we first needed to redesign care systems in communities across the state. When we got that right, we would invest in HIT systems to support - not lead - the changes.

Overall, the initiative has been a success. Avoidable hospital use is down and on track to be reduced by 25 per cent by the end of the decade; two-thirds of all provider payments are now value-based – meaning they reward effective, integrated care; hundreds of new care models are in the field; and the overall quality of primary care has improved through targeted investments designed to raise GPs to national standards of quality and care management. In addition, innovative new approaches to address the social determinants of health – such as housing, healthy food and employment – are being implemented across New York.

Our digital strategy sought to support these reforms on two levels:

First, we built off existing HIT systems to ensure that the government had clear sightlines into statewide performance. Funding for the initiative was linked directly to outcomes so it was essential that the state understood what was going on across the entire geography.

This new system proved exceptionally valuable and helped the state to ensure that overall performance goals were achieved and that outcomes continued to trend in the right direction. The approach enabled us to remain nimble and flexible; able to respond immediately when performance was not reaching targets, and to engage in continuous improvement.

The second level was to support provider groups in their efforts to successfully integrate, transform, and hold themselves to account. The program divided providers into integrated care systems – called Performing Provider Systems (PPS) – each with the responsibility of implementing strategies to better manage population health and drive clinical improvements across their region. PPSs, ranging in size from 25,000 to 1 million patients, needed tools to measure their progress and hold individual organisations accountable for their performance.

We used an existing data warehouse hosted by our strategic partner, CMA, for this purpose and built a variety of analytics platforms to make the data (new and existing) actionable for PPSs. This approach ensured that all PPSs had a base level of functionality while not preventing the groups from making additional investments or using exiting tools.

So, what does the New York experience mean for the NHS?

The overall model of health and social care integration is almost exactly the same in the NHS as it was in New York. The PPS structure created in New York State is practically identical to the developing Integrated Care Systems (ICS) across England. The challenge of how you support both the ICS layer as well as central governance is precisely the same.

I firmly believe the NHS should pursue a similar strategy and deploy solutions that build off existing systems, ensure base-level functionality for all, and allow flexibility at the ICS level so that local innovation remains possible. Such an approach would be cost-effective, while avoiding the trap of ’one-size-fits-all’ implementation, which will likely fail as each ICS is unique, serving a unique population.

For system reforms to be successful, the NHS needs to support integrated care implementation with investment in HIT. However, health leaders shouldn’t assume a single, fully-integrated, expensive solution is best. Instead, they need to make targeted investments at multiple levels with a clear plan for supporting system transformation.

Jason Helgerson is a social change agent, with over 20 years of public service, most recently as New York's Medicaid Director. An internationally recognised leader in public sector healthcare, Jason led the transformation of New York's Medicaid programme, reducing spending by $17 billion over the first five years.

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