DHIS International 2019 White Paper

In preparation for this symposium, KLAS gathered feedback from individuals at 132 organisations regarding the biggest challenges they are trying to solve through IT investment over the next two to three years. Respondents included decision makers from 39 countries across six continents. KLAS did not reach out to US organisations for this survey.

The responses to the survey indicate that a number of provider organisations want to invest in departmental/niche solutions (e.g., clinical decision support, CPOE/ePrescribing, RIS/PACS, billing, and document management). However, many emphasised emerging technologies—such as AI, machine learning, telehealth, and emerging patient engagement solutions—or solutions that help provider organisations get the most out of their systems through optimisation and efficiency-improvement efforts. These results determined the topics discussed at the symposium itself.

The following sections describe the biggest takeaways from symposium discussions. All quotations represent the remarks of symposium attendees.

IT Investment Areas with Highest Potential Impact

The symposium’s initial discussions centered on which of the investment areas highlighted by survey respondents could have the biggest impact on patient care. Attendees’ responses are noted below:

Of healthcare organisations’ listed top priorities for investment, which can or will have the biggest clinical impact?

1. Patient engagement
2. AI/BI
3. Integration
4. Telehealth
5. System optimisation/clinician efficiency

Niche vs. Enterprise Approach

Notably, niche solutions did not make the list of high-impact solutions. So why are provider organisations interested in investing in them?

“Departments want to take initiative, and that can lead to niche solutions because the departments can’t wait for enterprise strategies. Electronic data without governance will not work adequately. There has to be an investment strategy.”

Attendees noted the responsibility of healthcare leaders to help move decisions from the departmental level to the enterprise level (where appropriate) to tie together seemingly disparate decisions into a stronger, enterprise strategy.

Barriers to IT Progress and Adoption

The focus of the discussion then shifted to identifying the biggest barriers organisations encounter when adopting these technologies and what it will take to overcome them.

What are the biggest barriers to progress and adoption? 

1. Transparency/vision and strategy
2. Interoperability/standards
3. Evidence of ROI/outcomes
4. Regulatory definitions (e.g., for privacy)

Many attendees mentioned a lack of vision and strategy at the enterprise level. They argued that, overall, leadership is lacking for enterprise IT strategies.

“IT groups tend to be very reactive. Departmental groups often actually make decisions and then come to the IT group for implementation. Strategy has to be built with a clinician-centric view from the beginning and have a vision. You have to have a CIO that sits on an equal level with the medical director.”

“If you just try to use IT to enable old workflows and don’t focus on change, you’re throwing your money in the garbage.”

They noted the need for leaders to better define and drive the outcomes they hope to get from IT solutions so that they can sell their vision to board members and get buy-in. Provider organisations want more help from their potential suppliers in understanding a product’s potential, and they want suppliers to focus on outcomes rather than just selling widgets.

“How can the vendors help us get past procurement and get the innovation in front of the executive suite? What we have observed is that the supplier that comes in to show us innovative, really cool technology isn’t really helping us with getting past procurement. What we need is more of a partnership as we get ready to go to the executive board to seek funding.”

Policies & Regulation

Governmental policies and regulations were frequently cited as big barriers to IT adoption. Policies that are unclear or otherwise insufficient inhibit adoption of new, innovative solutions and prevent people from sharing and accessing data, capabilities that will be key in the new patient-care paradigm that is focused more on wellness and prevention than traditional episodic care. Below are insights from attendees on how to remove policy- and regulation-related barriers; notably, attendees feel that the removal of these barriers is essential to providing the highest level of patient care.

What needs to happen to policies at regional and/or national levels to remove barriers and speed up the adoption of beneficial technology?

Make it easier for suppliers and patients to access and share patient data

Data sharing is one of the biggest challenges hospitals face. Privacy laws make it especially difficult for organisations to adopt technologies that support the shifting healthcare paradigm (e.g., patient engagement, telehealth, and population health management solutions). Geographic barriers—not only between countries but also within countries—and privacy barriers between organisations represent a significant challenge, making it difficult or even impossible for providers to access outside patient data. Even when it is possible, data sharing generally isn’t a quick process (see interoperability section below).

“Regional differences in permissions for sharing data make interoperable exchanges incredibly difficult. Regulations broken out by region like this make it impossible to have a comprehensive medical record that covers the lifespan of a patient.”

Different organisations and countries vary widely in how they define patient-data ownership (i.e., data portability) and in how they manage patient consent for data sharing. Policy makers need to more clearly define and standardise patient data ownership.

“It would be valuable if regions could create a regional sharing agreement so that patient data could be shared across all the health networks in that region. For example, in Valencia, they simplify data sharing by allowing consent forms that are open enough to allow any clinician providing care to access that patient’s records.”

 “Can we [as an industry] help confirm that the patient should have access to their data? . . . Fear gets in the way of sharing. Usually the technology is there, but we are not sharing between different organisations. This is about overcoming cultural issues rather than technology issues.” 

Often, organisations take an opt-in approach to data sharing because of the aforementioned fears. However, many countries that use an opt-in approach for their programmes experience slow uptake, preventing widespread success. An opt-out approach is generally more successful with things like patient consent for data sharing or even organ donation:

“In the Netherlands, they just switched from an opt-in approach to an opt-out approach [in patient data sharing] for the organ donor programme, which has shifted the availability of organ donations.”

Create more clearly defined country-specific standards

Symposium attendees highlighted the need for clearer publication of local regulations and a common-sense approach to procurement, especially in the EU. Today, procurement requirements can be prohibitive to new, innovative companies, and a lack of clarity around local regulations can also make it difficult for these technologies to be adopted in certain countries.

“In Ireland we have a group of clinicians that are producing pages and pages to meet requirements for procurement, and there is so much information that people won’t even read the papers. We need to have more basic and clear information on how vendors can meet those needs. I’m trying to change our procurement process. . . . Procurement rules are heavy on anti-corruption practices and are not focused on a common-sense approach. There is a lack of interest in end users and patients.”

Improve interoperability

The inability to share data between systems is one of the biggest barriers to population health efforts today. Not having clearly defined guidelines for suppliers around data formatting and required content (similar to DICOM standards in radiology) can lead to a lack of collaboration and data sharing between healthcare providers, meaning clinicians won’t have access to all necessary patient information when providing care.

“There is a dependence on interoperability, but there are variations in standards. . . . Vendors providing the core systems charge huge amounts to interface for citizen solutions. Policy needs to stop people from charging so much and blocking interfaces.”

The ultimate goal of interoperability is the creation of a complete patient record, and some symposium participants suggested that a unique patient identifier would help with that goal.

During the symposium, attendees split into groups for breakout discussions on patient engagement—the area identified as having the highest potential clinical impact. The graphic to the right illustrates a patient engagement framework for US organisations developed by provider organisations and vendors in a previous KLAS summit. However, the application of patient engagement varies significantly from country to country. Below are insights from symposium attendees on how organisations around the world are tackling patient engagement.

Patient Access

Patient access was brought up less frequently in breakout discussions. While patient access tools are commonly used in the US for things like patient account management (e.g., paying bills), these types of applications don’t transcend all geographic borders, especially for countries with a single-payer system or more universal healthcare. A patient access application that was more commonly referenced by attendees is self-scheduling, though many organisations, especially in countries with public healthcare and waitlist requirements, are hesitant to enable this functionality.

During the afternoon, four panels were convened on high-interest IT investment areas, and audience members could ask industry experts about trends and challenges in these areas. Below are key highlights from these panels.

AI & BI

Panel Participants

Dr. Jenny Shao, Director of Health Information Systems, United Family Healthcare

Alexander Klemm, CTO, radprax MVZ GmbH

Brendan Farmer, Managing Director UK & Europe, Health Catalyst

Dr. Anjum Ahmed, Global Director of Imaging Information Systems, Agfa HealthCare

Notable Topics and Remarks 

What are the real applications of AI and machine learning in use today?

“We have a mammography screening programme where we have hundreds of thousands of people getting mammography. We have double blind reading, but we have a lack of radiologists who can do this reading, so we are trying some AI algorithms to filter out all the [negative] cases. The hype that AI does everything alone and that we don’t need the doctors anymore is not true. I would like to get the doctors more time to be with their patients and to dig deeper into the relevant cases and not the irrelevant cases.”—Alexander Klemm

“A good example is imaging a lung condition for TB on a DR. The system will flag some images as abnormal based on the size, the location, and the density. These are then passed to the radiologist for further clinical diagnosis. The purpose of using this technology is to reduce burden and help a junior doctor. This is one way to approach use of technology to just reduce the burden of the work on clinicians.”—Jenny Shao

What is the ideal application of AI?

“The ability to aggregate clinical knowledge or information from EPRs and correlate them with the medical imaging informatics—that is the Holy Grail. When I speak with radiologists, diagnosticians, or oncologists, this is what they are interested in.” —Dr. Anjum Ahmed

Outside of radiology, what use cases of AI/BI are most compelling?

• Triage
• Sepsis
• Patient no-show reduction

What will successful future adoption of AI require?

• “Beautiful” technology
• Appropriate physician engagement, including training from evidence-based knowledge
• Quicker response from regulators and policy makers

Interoperability

Panel Participants

Adrian Byrne, CIO, University Hospital Southampton NHS Foundation Trust

Osama Elhassan, Head of e-Health Section, Dubai Health Authority

Richard Strong, VP & Managing Director, EMEA, Allscripts

Notable Topics and Remarks 

What should interoperability look like in the future?

“One of the main ways [interoperability needs to change] is how it operates. Currently, it’s very much a push-based system. So it’s about people having data to share and then pushing it around, like with HIEs where people log in to see data pushed there by a secondary care provider. . . . Over the next three years, we should see more emerging services based on more of a pull-based model where we can leverage FHIR using an API to call to get information rather than relying on people pushing things around. . . . Another reason why it’s difficult to transfer information is a lack of coding and terming. [The information we’re pushing around] doesn’t become understandable unless we have it coded and termed properly. So we’re all hoping over the next three years to have achieved semantic interoperability through the use of discernment terminology within the data.”—Adrian Byrne

“Semantic harmonising is incredibly important. If the data isn’t put into the right coding form in the first place, you’re never going to get it harmonised with the other systems. It also must be presented to the clinicians in a way that ensures they understand it has come from another system. That harmonisation is essential.”—Richard Strong

Why is FHIR taking so long?

“A lot of people are talking about FHIR, but not a lot is happening. I think one of the reasons is that people are just waiting for this perfect standard to emerge. They want everything to be plug and play, and they want the system to just come out of the box and talk to other systems. In my experience, that is not going to happen. I think that we have to accept an imperfect world.”—Adrian Byrne

“There is something to be said about everybody being a little bit patient. This is the first time we’ve properly tried to have a global set of interoperability standards. And I think it’s going to take a little while for real traction to galvanise around that.”—Andy Kinnear (audience member)

Telehealth

Panel Participants

David Walliker, CIO, Liverpool Women’s NHS Foundation Trust and Royal Liverpool & Broadgreen University Hospitals NHS Trust

Joseph DeVivo, CEO, InTouch Health

Rachel Dunscombe, CEO, NHS Digital Academy

Notable Topics and Remarks 

Why telehealth?

“We look at telehealth very much like a power grid where if you have excess capacity in a certain area, there is no battery to store it if there is extra energy; instead, you have to move it to another municipality and sell that energy. It is the same thing in healthcare where specialists just reside in clusters, but the patients reside everywhere. The issues with telehealth exist in every country and in every municipality where the existing regulatory reimbursement policies are not designed for virtual care. There are costs associated with virtual care, so it should not be a discount. Policies should provide reimbursement for a virtual visit in the same manner as an inpatient visit. What you will find is that all of your facilities will balance the load. Compare it to the digitisation of banking. 20 years after the move to digital technology, banks didn’t go out of business—they just adjusted. They took all the high-volume, low-value transactions out of the facilities. They delighted their consumers who actually stepped in to do all these basic tasks themselves. And banking hasn’t gone away; the largest building in many cities is still owned by a bank. Banks might not have as many employees or branches, and the people who go into the branches only go for a complex transaction. I think that is pretty analogous to health systems and virtual care.”—Joe DeVivo

What real use cases of telehealth are in place today? What outcomes are being realised?

“We have a brand new hospital opening with 60 fewer beds to go along with all the talk of moving the patients out of the hospitals. When we looked at our patient cohorts, we identified that we essentially had three types of patients we thought we could provide care to in another setting: COPD, heart disease, and diabetes patients. Our drive was to reduce the length of stay in hospital and free up the bed for somebody else, or to prevent the patient showing up at the emergency room or walk-in centre needing an acute admission because their condition had deteriorated. So the investment was a bit of a no-brainer for us. . . . Today, we have 2,000 patients in Liverpool being remotely monitored. . . . [In terms of outcomes], we have identified 22%–32% reduction in emergency room admissions for those patients with COPD and heart disease. We have seen a 15%–20% reduction in diabetes admissions.”—David Walliker

What are the biggest barriers and challenges to telehealth?

“There are so many single-payer markets worldwide. The best beneficiary for telehealth is a single-payer market, but there are policies in some countries where reimbursement does not exist for a virtual visit due to a lack of understanding. Or it could be due to other barriers, such as credentialing, reimbursement, liability, and other things that were created for a system that is now archaic.”—Joe DeVivo

“Certainly in the UK and also in other parts of the world, there are very few commissioners who actually get the value of telehealth. In essence, with telehealth visits, you end up not being paid or only get a fraction of the actual cost you would have got for a face-to-face visit. Those are barriers because people haven’t re-imagined the new way of working and how you will pay for that systemically. . . . A slightly broken commissioning or reimbursement model is pushing a number of nations to not do things that would logically help the healthcare system.”—Rachel Dunscombe

What are some common misconceptions in the industry around telehealth?

“The biggest misconception we had was that we were going to dehumanise the medical interaction by putting a screen in front of the clinician. But what we find is that now, clinicians actually spend more time talking about what the patient needs. That means ¬higher-quality time together, and the patients much prefer it because they are not having to park, come into the office, wait, get into the room, have the chit chat, and then get to the appointment piece. Virtual care is very efficient. And while people worried we would dehumanise the medical interaction, we found that it was the opposite.” —David Walliker

“One misconception we heard was that it would take less time to use telehealth, and that isn’t always true. Instead, we should look at reducing our building space as part of our real estate strategy. For me, the misconception was really how the board considered telehealth. They didn’t consider it as part of a wider organisational change, but rather as something that stood by itself.”—Rachel Dunscombe

“Compare [telehealth] to the digitisation of banking. 20 years after the move to digital technology, banks didn’t go out of business—they just adjusted. They took all the high-volume, low-value transactions out of the facilities. They delighted their consumers who actually stepped in to do all these basic tasks themselves. And banking hasn’t gone away; the largest building in many cities is still owned by a bank. Banks might not have as many employees or branches, and the people who go into the branches only go for a complex transaction. I think that is pretty analogous to health systems and virtual care.” —Joe DeVivo

VNAs & Enterprise Imaging

Panel Participants

Marco Foracchia, CIO, Azienda USL di Reggio Emilia

Razvan Atanasiu, CTO, Hyland Healthcare

Dr. Rizwan Malik, Clinical Lead for Radiology, Royal Bolton NHS Foundation Trust

Notable Topics and Remarks 

What best practices do you recommend for enterprise imaging?

“Have a strategy. Get buy in. Understand that enterprise imaging is not just your radiology, cardiology, and mammography needs. Those may generate revenue right now, but there are so many other departments.” —Razvan Atanasiu

How can an organisation get buy-in from leadership?

“The first thing we did was look inside our organisation to see what other areas were left behind in terms of data management [besides the department that was asking for enterprise imaging], and we found out that there were several other types of data (like images, videos, and sounds) that were not managed. We call them the leftovers from the big ICT process. We did a structured study where we actually categorised and measured all of these different data sources. Taken individually, these were not problems that I could take to my CEO and ask for investments on because they were too small. But taken as a whole, they were an issue that could be meaningful in terms of investment. So that was the first step we took, and it was very important because it motivated our board to actually finance the project. Then we started to actually look for technologies.”—Marco Foracchia

What can organisations do to ensure that their enterprise imaging supplier delivers what the organisation truly needs and expects?

“Don’t get hung up on labels—just describe what it is you want. When a procurer puts a label on something or puts something down on paper, it becomes an entity unto itself, not necessarily what you want it to be. For example, anytime you ask the supplier, “Can you do this?” the answer is always going to be yes. For example, if I ask, “Can you turn this blue square red?” that means to me it will take one click or even no clicks to turn it red. The supplier will say yes to that request, but they don’t mention that it will takes 27 steps and you will have to stand on your left foot and twirl around three times for it to happen. Instead of asking yes/no questions, present the supplier with pain points or with your ideal state, and then ask them to demonstrate how they can solve it. That makes for a more mature dialogue.”
—Dr. Rizwan Malik

Healthcare Industry Leaders

Anjum Ahmed, Global Director Imaging Information Systems, Agfa HealthCare

Kathleen Aller, Director of Market Strategy, Healthcare, Intersystems

Mohammad Al-Ubaydli, CEO and Founder, Patients Know Best

Massimo Angileri, Regional Business Manager, Europe and Emerging Markets | Healthcare Information Solutions, Carestream Health

Yasemin Arik, Investment Professional, HG Capital

Raz Atanasiu, CIO, Hyland

Julian Bennett, Principal, Investcorp

Janez Bensa, CEO, Parsek

Andreia Beyer, Global Director of Marketing and Growth Opportunities

Guido Botticher, Managing Director, VISUS

Marc Brunet, President & CE, Logibec

Adrian Byrne, CIO, University Hospital Southampton NHS Foundation Trust Carestream Health

Gasper Cehovin, COO, Parsek

Richard Corbridge, Director of Innovation, Boots UK

Martin Curley, Director, Digital Academy and Open Innovation, Health Service Executive

Joseph DeVivo, CEO, InTouch Health

Timothy Dowdell, Radiologist-in-Chief, St. Michael's Hospital, Toronto

Rachel Dunscombe, CEO, NHS Digital Academy

Osama El Hassan, Specialist, Dubai Health Authority

Mohamed El Shahed, CEO, National Technology

Mirit Eldor, SVP Strategy - Health Markets, Elsevier

Brendan Farmer, Managing Director UK & Europe, Health Catalyst

Kareem Fatehy, CEO, Pulse for Integrated Solutions

Marco Foracchia, CIO, AUSL Reggio Emilia

Alan Fowles, President of Global, Allscripts

Jerome Galbrun, Global Head of Marketing, Philips EMR Business

Jarrod Germano, General Manager, HCI Europe, HCI Group

Tomaz Gornik, CEO, Better

Marc Hadwin, Head of Digital Services, Morecambe Bay Hospitals NHS Trust

Marieke Hanegraaf, Project Leader, Registratie aan de Bron

Sam Hendler, Managing Director, Harris Williams

Rudolf Heupel, Sales Director DACH, VISUS Health IT GmbH

Mark Hutchinson, CIO, Gloucestershire Hospitals NHS Trust

Aaron Jones, Chief Nursing Information Officer, Sydney Local Health District

Erez Kestenband, Innovation Leader Precision Diagnosis, Philips

Andy Kinnear, BCS Health Chair, BCS

Alexander Klemm, CTO, radprax MVZ GmbH 

Hajo Kroesche, Director, EQT Partners GmbH

Marcel Lantinga, Managing Director EMEA, Vital Images Europe B.V.

David Lee, Medical Director, DXC Technology

Veronique Lessens, Global Head of Strategy, Marketing & Communication - HE/Market Intelligence, Agfa HealthCare

Willi Lohrke, Sales Director, International, VISUS

Anthony Lundrigan, CIO, Norfolk and Norwich University Hospital NHS Trust

Rizwan Malik, Consultant Radiologist, Royal Bolton NHS Foundation Trust

Vicent Mancho Mas, CIO, MARINA SALUD S.A.

Rob McGovern, Co-Founder, Malinko Healthcare

Sarah Moorhead, Associate Director of Digital, Leeds Teaching Hospitals Trust

Tomas Mora Morrison, Founder & Owner, Cambio Healthcare Systems AB

Giorgio Moretti, CEO, Dedalus

Michael O'Neil, Founder & CEO, GetWellNetwork

Julien Oussadon, Director, Harris Williams

Mario Razzini, Prinicipal, Francisco Partners

Angela Reed, Chair, UK And Ireland Chief Nursing Officer Digital Leadership Group, Northern Ireland Practice And Education Council For Nursing And Midwifery

Jacques Rossler, CIO, Cliniques Universitaires Saint-Luc

Jenny Shao, Director, Health Information Systems, United Family Healthcare

Nasser Shehata, CEO, Health Insights

Joyce Simons, Program Manager, Registratie aan de Bron

Richard Strong, Vice President & Managing Director EMEA, Allscripts

Marta Szczerba, Associate, KKR

Ziad Tabet, Partner, IQVIA

Michelle Tempest, Healthcare Superhero, Candesic Ltd.

David Walliker, Chief Information Officer, Royal Liverpool Hospital

Ahmad Yahya, Chief Information Officer, American Hospital Dubai

KLAS Attendees

Tara Alba, Event Coordinator

Chris Chandler, Research Director, Investor Services

Jon Christensen, Global Leader, Arch Collaborative

Adam Gale, President

Jeremy Goff, VP, International Clinical & Services Solutions

Jared Jeffrey, Director of Strategic Relations 

Mitch Josephson, Director, Arch Collaborative Research & Analysis 

Lois Krotz, Director of Research Strategy

Eder Lagemann, Research Director

Bobby Low, VP, Customer Insights Strategy & Analysis

Monique Rasband, Research Director

Everton Santos, Research Director