Richard Corbridge, first Chief Information Officer of the Health Service Executive (HSE) and CEO of the newly created eHealth Ireland, discusses Ireland’s ambitious plan to construct a new digital health fabric for the country, its nine-year strategy with the aim of achieving something tangible each year, his plans for dealing with privacy concerns, and his thoughts on the role of the CIO.
You were brought in to set up Ireland’s digital health infrastructure at the HSE. Can you first introduce yourself to our international audience?
“Fundamentally, we wanted to be sure that the e-health agenda was clinician-driven rather than technology-driven.”
My background is entirely in healthcare technology. I spent nearly twenty years in healthcare in the National Health Service (NHS) in England, with both the National Institute for Health Research (NIHR) overseeing clinical research, and with the delivery of NHS services in the UK.
I have been in Ireland two years now as the Chief Information Officer for the Health Service Executive, the Irish National Health Service, as well as CEO for eHealth Ireland, which is a program that we have put in place. Prior to this, Ireland has not invested in health technology for a decade.
eHealth Ireland is a program of work rather than a separate organization to the HSE, using government investment to find and use digital solutions to make the Irish healthcare system safer, more efficient and more agile. We intend for eHealth Ireland to become the owner and proponent of the digital health agenda for Ireland. It will have responsibility for many aspects of Ireland’s digital health, including the infrastructure design, delivery of eHealth and clinical leadership, and the integration of systems into one single source to safeguard access to information.
You were essentially meant to build Ireland’s digital healthcare infrastructure from scratch. When you first arrived, what was your first priority?
The prioritization has focused on creating foundations. The team I inherited in November 2014 had been very localized, distributed across Ireland based on geography rather than in terms of their functions or responsibilities. The whole team has been through a big cultural change to become a national digital team. We have a national design team that makes design decisions on what solutions we buy, we have a national PMO team that does the delivery, and national directors that look at primary care, acute services and community health. We have split our functions to look at the way care is delivered instead of the way IT is delivered.
Fundamentally, we wanted to be sure that the e-health agenda was clinician-driven rather than technology-driven. This is why we have appointed a chief clinical information officer, who is also the deputy CIO and sits on the senior management team of my organization, eHealth. The World Health Organization (WHO) has even commented that our progress is remarkable for a country that has arrived so late to the game. We now have over 220 chief clinical information officers supporting our activities across Ireland.
We have a nine-year program, so we wanted to start with the basics like the IHI, which are essential for electronic health records (EHRs) to work in Ireland. We are creating the business case for an EHR, so we would need an IHI to do and deliver that. The changing of the teams into a more structured and less wasteful function was done by March and we had a new operating model that we are now moving towards.
eHealth Ireland currently has ten strategic programs. Can you outline some key initiatives that have already been successfully introduced?
eHealth Ireland has an overarching nine-year plan, but we have said to the Minister of Health, each year we will set out and achieve several smaller tangible goals. We are not going to work away in silence for nine years and come back with a completely new system. We have published the Knowledge and Information Plan, effectively a road map for Ireland that sets out a budget, strategic goals and processes.
This year, we have had two key initiatives. The first is the individual health identifier (IHI), a unique identifier for patients that will follow them whenever they seek healthcare. In about 12 months, we went from a standing start to creating the actual technology – so that every person in Ireland now has an IHI.
We have also implemented the ability to do electronic referrals, so every GP practice can now digitally refer a patient into a hospital for their acute appointments.
Next year, we anticipate implementing electronic discharge messages, the first stage of e-pharmacies, and a portal for patients to use.
Ultimately, we want to present a useful new initiative each year.
Were you surprised by how different the Irish healthcare landscape was compared to the English one?
The Irish healthcare system is not like the English NHS at all. Most obviously, the lack of a free healthcare system in Ireland makes technology implementation more challenging. Ireland has also had quite a local healthcare system that is anchored on individual hospitals until quite recently. Money has also mainly been spent on what is known as the voluntary sector rather than the HSE, which means their approach to digital health would have differed from the public sector’s.
I also remember that when I arrived two years ago, a study on Irish health technology solutions had suggested that Ireland was around sixteen years behind the NHS, which is a huge leap, so I came prepared for a lot of changes to be made.
What turned out to be a pleasant surprise was that the gap in reality was not as big as it seemed, because there were many localized centers of excellence, usually based on particular hospitals, with a phenomenal quality of care. One hospital would have a great EHR system for epilepsy, another would have an excellent supply chain management system for hemophilia, so these were all competences that we have been able to capture and extend across the country.
You have also been quoted as saying that Ireland can leapfrog the UK by 2020 if it learns from the lessons of the English NHS and others globally. What are the most pertinent lessons?
That clinical leadership I have outlined is the first and biggest lesson: to make sure what we do is led by clinicians instead of technology. Secondly, as I just discussed, we want to integrate existing infrastructure and local competences instead of ripping everything up and implanting a new monolithic government system.
Very critically, we are also ensuring that privacy and consent issues are considered from the very beginning. As an example, with the IHI, we created two consent flags allowing patients to indicate whether they want to share their information for firstly, clinical practice, and secondly, clinical research. This means that patients are empowered to make decisions about their medical information. Another initiative we have introduced is to give patients the ability to audit who has looked at their information. They will be able to log onto a centralized portal and find out which clinicians have looked at their health records.
It is not just England we can learn from. Globally, many countries are doing extraordinary things in the area of digital healthcare. Estonia is a model in terms of patient empowerment on health information, Canada has been able to integrate different systems and information pathways together very well, and the UK has lots of best practices surrounding clinical research and making information available for genomic sequencing.
Perhaps unexpectedly, being a relative latecomer to the game allows Ireland to catch up quickly by learning from all these lessons from other countries.
Could you highlight some of the most innovative approaches eHealth Ireland are taking?
The EHR is the biggest ongoing project. We are trying all sorts of innovative approaches in its design and procurement. For instance, instead of releasing the typical lengthy instruction booklet for potential suppliers detailing what our desired EHR system should look like, which is quite a static approach, we are creating instead a simulation website. It will have twenty personas of various healthcare stakeholders, including patients with different diseases, clinicians in different specialties, etc. These people are given full profiles.
When we go to our suppliers we will ask them how their systems could work for these profiles. We can then test their systems using these personas to give us a more accurate idea of how their technologies will work to benefit the lives of the people in Ireland.
At a later stage, we will also allow the general public to access the website and provide feedback. It is all about promoting more engagement within the process for better outcomes.
A critical factor for success is public perception and support of these digital health initiatives. What would you say to sceptics that may wonder, why is the HSE spending, for instance the EUR 900 million on the EHR program, when it is likely to go over budget by EUR 350 million this year?
It must be emphasized that the EUR 900 million will be spent over nine years. When you break it down, it is about EUR 17 per patient per year.
The flipside is that if you want to have a better health system that can offer integrated care; you need to invest in what we call a digital fabric. You cannot have integrated care with paper and pen.
When people talk about personalized care in other countries, we talk about contextualized care in Ireland. Personalized care allows them to say how old, who you are and your background. What matters is also where you are now, where you are going, and how your family is doing. Without that kind of information, you cannot have the sort of contextualized care we are talking about. You cannot do that on paper.
There is a real drive towards creating this digital fabric.
There is a huge element of public engagement and perception of course, not least with the data privacy issue. How are you engaging with key healthcare stakeholders and the public on all your digital health initiatives?
We have been very open and transparent. All of our documentation goes on the eHealth Ireland website straight away, which has enabled us to build up a positive relationship with the media, because they feel part of the journey.
We have also embraced social media, for instance, we regularly cohost “#Irishmed” Twitter hour, where a chair asks a question every fifteen minutes and invites people to respond on Twitter. The last twitter hour we did there were 4 million impressions in just one hour.
I have also been on the stage, doing a lot of public speaking events to raise awareness of what we are doing.
The pharma industry has also been an invaluable partner. For instance, we are working with Pfizer to look at drug-med reconciliation. Typically, when a patient leaves a hospital to return to the community care setting, the GP reissues the prescription and new drugs. We have launched a pilot in three hospitals to facilitate digital reconciliation of medicines so that when patients return to the community setting, the GP can just top-up your drug needs.
We are also working with professional associations and patient groups in key initiatives. With the Genomic Sequencing for epilepsy project, we work with the Royal College of Surgeons in Ireland (RCSI). It is 50 percent clinical research and 50 percent clinical treatment with consenting patients, and thus far, we have already sequenced about 40,000 patients with epilepsy.
This calendar year, we have focused on improving the way we work with start-ups. In November, we will have a whole week dedicated to the promotion of health innovation, with speaker sessions and activities organized.
Generally speaking, the public perception is ‘please get on with this’. Dublin is an European digital hub, and yet our healthcare system is still probably very behind within the EU in terms of actually adopting digital health technology. It is a bit frustrating because the technology has undeniably arrived, especially in Ireland with its booming tech industry, but it is a matter of changing the business mentality and attitudes to accommodate it. But hopefully this will change very soon.
On a more personal note, how have you seen the role of the CIO evolve in the past two decades?
To move from a technology space to a business space is dramatically different. Instead of just interacting behind the scenes with programmers and network engineers, you now have a very public-facing role where you need to communicate ideas in person and writing, in an accessible and engaging way. It is certainly more enjoyable and personable, but also very challenging.
I was teaching a group of prospective CIOs a while ago, and I said, unless you are prepared to be a little bit famous, you do not want this job!