‘When we get it right, IT is the sewage system of the 21st century’

Agents of change: Geraint Martin, Annette Hicks, and Sarah Thirlwall

Geraint Martin says healthcare is at the ‘cusp of a revolution’, similar to what banking faced years ago.

The CEO of Counties Manukau District Health Board (CMDHB) cites how the smartphone, for instance, transformed the banking industry.

The banking model has evolved from where customers needed to go to the bank to cash a cheque or book an appointment to talk to the bank manager, to one where they can access their account and speak to the bank representative, through their smartphone.

“Health is on the cusp of that coming through,” he says. “We have to accept the world is becoming more and more IT connected and health has to respond to that.

“It is also about people’s expectations,” he says. “Instead of the patient thinking ‘I will have healthcare when I am in crisis or when I meet an accident’…the key to having a sustainable health system of the future is having patients continuously interacting with health and with people who will keep them well.”

This, he says, is part a driver for the DHB’s launching of the SWIFT program.

Project SWIFT (System Wide Integration for Transformation) began last year, and the DHB chose IBM as its implementation partner following an RFP.

“We knew we were under-investing in our technology solutions, so we took exactly the same approach as an enterprise would,” explains Sarah Thirlwall, director strategic ICT transformation at the CMDHB.

“If that’s our business, let us make sure we understand what we want out of that business, and then understand how we will use technology to enable that.

“But let us look at it from a holistic point of view.”

By giving people the right information but also utilising big data so we can come up with new and innovative ways of working… that is the third revolution in healthcareGeraint Martin, Counties Manukau District Health Board

Thirlwall says SWIFT involves working “with the whole system”, alongside other organisations like healthAlliance, primary health organisations and communities. Lessons from the SWIFT project will be shared with the other DHBs in the region and nationally.

The project is being undertaken in association with the New Zealand Health Innovation Hub, the Ministry of Business, Innovation and Employment, and supported by the National Health IT Board and the CEOs of all Northern Region district health boards

“We are now moving into understanding options and doing assessments, and making recommendations to our Board soon,” saysThirlwall.

Martin paraphrases a quote famously attributed to Albert Einstein on the importance of this assessment: “I can solve any problem as long as you give me 55 minutes to find what our problems are.”

He says the 55 minutes in finding the problem is more important than being tempted, for instance, to give everybody a smartphone.

“You do not get bang for your buck,” he says.

It was important for the DHB to stand back and understand the question the organisation is trying to answer.

“Now we have a real understanding that IT in a way [is like when] sewage drove the first health revolution, in the way that hospitals drove changes in the 20th century.”

“IT is the crucial bit of infrastructure that will change healthcare…when we get it right, IT is the sewage system of the 21st century,” he contends.

“IT is not glamorous, it is the bricks and mortars of the 21st century. It is the electricity system. It is not just a nice thing to have.”

Martin says if you go to business schools across the world and ask ‘what is the most complex organisation that exists?’ they would all say it is healthcare.

“Healthcare is phenomenally more complicated as a system than any other organisation.

“The IT challenge that sits underneath that complexity is exponential, one of the reasons why across the world, there is a lot of failed IT projects in healthcare.

“People misunderstood or underrated the impact of that complexity,” says Martin.

Thirlwall says at the same time it is important that the ICT team shows what is possibleand what is developing out there, as well as the opportunities using technology.

The 100-plus year old revolution

Geraint points out, however, that the health sector is actually now on its third phase of revolution.

The first revolution was getting sewage which led to improved health for the population. The second revolution involved the 20th century modern hospital, which meant improvements in surgery, hygiene, antibiotics as well as living standards.

“Life expectancy went up,” he says. “Unfortunately, we don’t live the last years as a 30-year-old, we live it like a 70 year old,” he states. This means living with chronic diseases like diabetes.

“To keep yourself healthy, the challenge is different now. It is not just about having efficient hospitals. It is how people continue to engage with their health for treating things like chronic kidney disease or diabetes.

“You will see who would be looked after the community,” he says. “It is about not having high end expensive hospitals overrun with people who can be treated in the community.”

The challenges then are: “How can we redesign the business model? How do we then utilise the potential of IT to really drive our change through health?”

He says this means becoming “patient centric”.

“By giving people the right information but also utilising big data so we can come up with new and innovative ways of working… that is the third revolution.”

“To do that we need to be much more sophisticated in terms of how we use IT,” says Martin.

He says it is about moving away from hospital or doctor to the patient being central to health.

Annette Hicks, subject matter expert in healthcare technology for IBM, and who is working with CMDHB on the SWIFT program, goes back to how technology impacted the traditional banks.

“It doesn’t take away the importance of having a bank, it is actually how you use the bank,” says Hicks. “But it also takes away the high value, low value transaction and putting it in the control of the family.”

Martin says a practical example is when people do not turn up for appointments. The DHB puts aside a clinic with a bunch of doctors and nurses. You send somebody an invitation to a consultation.

Martin says the traditional way of doing that is sending a letter to the patient.

“We never asked, is that convenient to the patients, we never asked a patient how they get to their appointments.”

Sarah Thirlwall

We understand there is an enormous amount of change for our staff, and we are making sure they are well supported and understand how to cope with that.Sarah Thirlwall, Counties Manukau DHB

Martin says sometimes people don’t attend, not because they are lazy or don’t care, but because “they have an 11:15 am appointment and they only have one car”.

“They need to go to work or they will need public transport. They may need four or five buses to go to the hospital, or have kids to care for.”

He says the DHB currently has an app where they can choose when they can be there.

“It is going to be about dealing with the management of chronic disease, with the patient playing a big role in its management using information.”

Big data is very much part of this ‘third revolution’ in healthcare.

“We are looking for a signal amidst the noise,” he says, referring to the information generated by various healthcare systems.

By analysing data, the DHB found that 11,000 of the 500,000 patients the DHB looks after drive half of their cost.

“The key to success is finding out how much of that 11,000 people you can change at the same time,” he says.

A big portion of those 11,000 people are also going through problems around education and (welfare) benefits, he says.

“How do we find that hard core of people we need to support better?

“The way to get better public service is thinking, how do we share data across the public sector so we can talk about resources we got?”

For instance, this could be linking the health system with that of Corrections and Housing.

“It could be around insulating their house to reduce chest infections. So if you give money to the housing sector, you improve spending in the health sector. How do we get clever at that?”

Related: The data science activist

Martin says success of this project requires a “central business driver, it requires leadership”.

“It is not one person, the organisation has to have the collective leadership to make this happen, and a collective courage and wisdom as well.”

The DHB as an innovation hub

Martin discusses the impact of SWIFT to the New Zealand health system.

CMDHB is one of the largest DHBs in New Zealand, servicing nearly half a million spanning a spectrum of the economy, ethnicity and age. “It is a world of microcosm,” says Martin on the area covered by the DHB.

“You can go through various parts of the world,” he says – as an area it covers, South Auckland, which hosts one of the largest Polynesian groups in the world. The DHB’s coverage spans agricultural areas, communities with strong Maori representation, the diverse ethnic groups in Howick, and the horse breeding area in Karaka.

“In the course of half an hour driving, you can go right around the world,” he says, smiling, “which makes it a very, very exciting place to come to work”.

The DHB also runs national services like the Spinal Surgery Rehabilitation and National Burn Centre, with the latter extending its services to South Pacific.

“But the important thing to bear in mind is we have got two tasks – to make sure when people need us, we treat them well, quickly, with kindness and compassion,” he says.

“Also, we work hard to ensure we are working as a whole system, it is not just as a district health board, to ensure the population is well so they can continue with their life.

The DHB is doing the first bit really well, he states, citing that the DHB is considered one of the safest systems in Australasia, and also very efficient.

“We are a lean, mean, quality machine.”

He believes the DHB could do more on the second task, of “keeping well in the community”.

He says this is one of the reasons behind the project SWIFT.

“How do we look at our business in hospital’s technical efficiency? How can we get a little bit more efficient?

“We have completely redesigned how we work, the whole system of GPs working with patients, physical therapists and other social services to keep people well.

“We have to completely redesign how we do business.”

“We need to be doing more with other sectors,” says Thirlwall, “talking to other agencies.”

Thirlwall adds: “Can we bring you closer to where you are, the specialists in the community?”

Martin cites, for instance, using videoconferencing between GPs and hospitals teams to discuss about a case.

Technology can be used to help support people at home. Or video or camera can be used to send images to a dermatologist who can talk to the GP on Skype in the consulting room.

“That takes out so many links to the chain.”

Martin also says there are privacy issues around this sharing of data that needs to be discussed with the Privacy Commissioner.

“How do we go about doing that because that is going to be absolutely critical” to the success of the program, he states.

He talks about having eight cars in the driveway of the affected family. Each one is from different government agencies, like health and justice. He says what is ideal is having these “eight people in one car”.

“We are getting there.”

Martin believes the biggest success has been the understanding and the input of everybody in the organisation on the program.

“They know we have to change, what needs to change, and what they can do to make it happen.”

One of them is understanding the application platforms they have, and categorising them – which ones meet their needs and must be kept up to date, which ones to disinvest or turn off.

“It is a good exercise exactly where our investment has gone, to look at what was important for us to take forward,” says Thirlwall.

“That is something an industry has to do, it gives you a map of where you want to go,” notes Annette Hicks of IBM.

Clinicians are helping design the ‘business systems of the future’

Another critical component of the program is working with the staff, including the medical team and technicians, in designing their “business systems for the future”.

“This is the innovation centre, we need to transform how we work to do that we need to build capability, build a track record to know what works and does not work,” says Martin. “We have an incredibly change ready organisation because we have invested in the capability of the people in the frontline.”

He says this includes working with frontline staff like doctors and nurses to “actually drive the change we need to see” and provide them with the skills that will help them do that.

“We have a meeting with the doctors, you don’t put the systems in and expect them to work. Healthcare is so complicated and so nuanced,” he says on the importance of frontline design.

Martin says a simple lesson on frontline design can be gleaned from public park pathways.

“In every park in the world, all too often, people build paths and expect people to walk there only to find they will cut a corner. They will try to stop cutting them using an overlap barrier.

“What you have got to do is watch where people walk, and then build a path, and be prepared to adjust it.”

“We are watching where people work, listening to them, the frontline people who work on databases, doctors and nurses.”

Taking care of ‘mindfulness’ Martin says supporting the staff in the new environment is critical.“We also have not been negligent of the impact of this speed, this instantaneousness of the information that we bring, to how people work.“Focusing on the world we are living, we are so incredibly hyper stimulated. Our brain has not evolved to cope with it all, and it triggers a lot of anxiety stress. “The way to counter that is mindfulness training,” says Martin. He says while staff is not required to take this training, it is made known to them that it’s available.He says staff who have taken the training also speak out about the importance of mindfulness in a “world that is incredibly stimulated by data and [the] and immediacy that IT brings”. Thirlwall, who has taken the mindfulness course, agrees. “We understand there is an enormous amount of change for our staff, and we are making sure they are well supported and understand how to cope with that.”

Geraint Martin, CEO of the Counties Manukau District Health Board visits the Wellness Centre at Middlemore Hospital

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