OHT Digital Health Playbook: Change demands more planning
Ontario Health Teams are poised to change how care is delivered in this province (my thoughts are here). Some have set the bar on what connected, collaborative leadership is, and this is certainly a reason to be optimistic. However, practical matters must still be addressed, and in my opinion the two biggest issues are digital health and physician payments.
We recently saw the release of the OHT Digital Health Playbook. It does an admirable job of guiding OHT leadership through the early stages to maturity, recognizing that it’s an iterative process that will require much support. However, there are three critical areas where the playbook and the attendant policy draft documents miss the mark. These three areas are all about change — where it will take place, how it will take place, and where it will come from in the future.
Change at the Right Level
The Playbook puts the onus for advancing digital health onto the OHTs. While it may appear enlightened to leave the vision and planning up to local leadership who will respond and react to local needs, this is highly flawed. Digital health needs are not as locally-driven as something like home care or community mental health supports, so the benefit to localization is not worth the loss of standardization and centralization.
Digital health is a domain that is highly complex, and in this era of reform and openness to change, it would be a real loss if we didn’t get this right. What’s at stake? Digital health needs change that is transformative, not merely incremental gains on a dysfunctional, heavily manual/paper/fax, luddite system. OHTs may not have the internal capacity to look at truly transformational changes because they cannot control the digital health assets and payment models outside their purview, they are constrained to a cost-benefit analysis that looks at their OHT, rather than the province as the unit of analysis, and they may not have the expertise required to get under the hood and examine the interoperability, privacy and other compliance requirements. OHT leadership is mostly based on volunteerism and secondment from other roles, and I think the digital health portfolio demands more than that. We cannot risk having OHTs make decisions that are “right” for the OHT but “wrong” for the province and its patients.
In my opinion, the province must listen to OHTs, patients, and other stakeholders to understand needs. It must have a venue to explore transformative digital health changes, and offer tangible steps in that direction. Most importantly, it must relieve OHTs of the burden of compliance as much as possible, not by reducing compliance requirements, but by offering to assist with the onerous due diligence required for something as sensitive and significant as digital health.
A Destination Without a Plan is Just a Dream
The Playbook lays out several instances of what will be possible at maturity. Unfortunately, there are very significant issues that must be addressed as part of any change plan, and the playbook makes no mention of them. These issues are data, money, and compliance.
Currently, data on Ontario’s 14 million or so patients are strewn across hundreds if not thousands of servers, be they in the closets, back rooms and basements of clinics and hospitals, or various cloud-based servers with warehouses across the country if not the world. Each of these repositories serves as the bedrock for clinical care, someone pays for them, and there is some point of equilibrium of cost and benefit that makes the entreprise justifiable. Oh, and one added quirk — the data does not migrate nicely from one setting to another. As we talk about a future state for digital health in Ontario, we have to understand that we are disrupting what is essentially a wild rainforest of data, and trying to turn it into an ordered botanical garden. How will we move data, and how will ensure that we don’t disrupt the clinical work during transition? If you’ve ever had to change an EMR, you know it’s not a simple copy/paste operation, and that’s without talking about training staff and rediscovering the nuances behind seemingly mundane clinical processes.
Digital health services must be considered through the lens of payment. Again, all current assets were paid for by somebody (often from physician take-home pay in your average clinic) or some institution. There’s a delicate balance of ROI, where the return is not just money but also efficiency, goodwill, etc. As we transition through the levels of digital health maturity at the OHT level, and OHTs themselves transition from teams that ideate to teams that procure, we must ask: who will pay for this? Will this replace current line items in the budget, or add another one? Will the return on investment be worthwhile only at a collective level, or also to the payer? For example, consider virtual visits. Patients are clamouring for it but aren’t paying for it under OHIP. Does it make sense for doctors to offer it, and invest in the software to make it available? It’s not always clear, and every change has to be as “worth it” as possible to the stakeholder making the bulk of the investment.
Finally, there are issues of compliance. What are the carrots and sticks that will get us from here (which we got to via a previous regime of well-intentioned carrots and sticks, so make what you will of that) to the promised land? What will incentivize OHTs and care providers to go beyond the strict minimums set out in OHT policy? What will keep others from dragging their feet, or more realistically, under-resourcing or under-prioritizing digital health? We need a coherent strategy on this that is collaborative (change with rather than change to) and learns the important lessons of previous policy misfires.
Innovation: Harnessing or Suppressing a Powerful Force
In my opinion, the Playbook focuses the reader on provincial digital health assets, presenting them as a full complement of services and assets that enable anything digital health can ever really offer. It fails to recognize that there are incredibly powerful assets that exist outside of this privileged group, and that there’s a wild, exciting future for digital health that we cannot yet imagine but that we must be able to participate in.
Let’s examine this sentence form the Playbook: “This would help minimize the proliferation of other technology solutions which would exacerbate the existing fragmentation in the technology landscape”. Yes, this is a sentence about e-referrals, and I will admit that I am heavily biased here as a co-founder of an unlisted/unacknowledged solution. However, the proliferation of solutions creates competition on value, usability, and cost. It only creates fragmentation because the ecosystem has not been set up to enable cohesiveness. The policy guidance on interoperability focuses on solutions developing APIs so they can talk to one another. However, this point-to-point connectivity has been promised for years, has yet to materialize meaningfully, and even then won’t create the kind of ecosystem that encourages competition and ingenuity, let alone meet the well-articulated needs of patients to access their full health records.
We need to be thoughtful about an information architecture that is built around connectivity and patient access. This is hard policy work regarding privacy, data governance and other vital areas, but we cannot shy away from it. Our architecture should also attempt to optimize for competition by reducing barriers to entry, reducing switching costs, and encouraging procurement (many possible models beyond the scope of this piece, such as vouchers for patients and providers) so that we get better products for cheaper cost. We must also be able to anticipate that there’s a future we do not yet fully understand, but will need to incorporate — think along the lines of remote monitoring, population data analysis, and even monetizing data through revenue-sharing agreements with patients who opt-in. I know that in 10 years the future will allow for possibilities my constrained 2019 mind cannot even grasp. Let our system architecture have the humility to believe that about itself as well.
Conclusion
The playbook raises concerns because it reduces the world of digital heath to provincial assets with significant existing flaws and downloads the integration work onto dozens of siloed, under-resourced OHTs. I know that the people working on this are highly intelligent and are treating this document as a work in progress. This is good. However, we still have work to do to identify the right level for change, facilitate transitions despite challenges with data and payment, and build a system architecture that anticipates an unimaginable future and is ready to harness the competitive entrepreneurial spirit. Without addressing these issues, this playbook risks wasting an important moment in Ontario’s health care history.
