The deadline where New Zealand will wake up to a new unified health system is fast approaching. In July 2022, 20 District Health Boards (DHBs) will become one entity called Health New Zealand. This new entity will work with the Māori Health Authority for primary, community, and kaupapa Māori services. Why is such drastic change needed in the New Zealand health system? Unfortunately, your access to and level of healthcare is dependent upon your post code. Living in a major urban district versus a rural district, may determine the efficacy of the health services you have access to. One way to help solve this issue is via healthcare data: to identify key issues to be addressed, track progress, and as part of the solution.

To start with, data from the Ministry of Health shows that key targets are currently not being met. For example, the Ministry of Health set the ‘Shorter Stays in Emergency Departments’ target of having 95% of patients either discharged or admitted within six hours. In the past three years, five or fewer DHBs have met this target according to the Ministry of Health’s own data, highlighting that critical key performance indicators are not being met. For example, in Q1 2020/2021, the shorter stays in the emergency department objective was achieved by only South Canterbury (95.3%), Tairawhiti (95.9%), and West Coast (97.9%) DHBs – the rest missed the 95% target, in most cases by a wide margin. And it is not just the shorter stays objective being missed. Another example during this same period is the faster cancer treatment objective, where only 11 of the 20 DHBs achieved the target of 90% of patients commencing treatment in 62 days. The gap between expectation and delivery is replicated across the healthcare system. Clearly the solution isn’t a simple one, nor will it be one dimensional, however the good news is that this restructuring is a once-in-a-generation opportunity to address the challenge.

Change is Hard, but Possible

Success requires a massive cultural change and mindset shift. We need to start thinking differently. This is not a matter of wait and see what happens, it is prudent that we address this issue now, head on. There are different ways to achieve the same outcome and we need to accept that what works in one DHB may not be appropriate for another DHB. Keep in mind, the health sector is not only a complex, interrelated clinical care system, it is also a massive repository of patient information. And it has a regulatory and ethical responsibility to protect patient privacy. Those charged with leading its technology development often feel that this requires custom solutions or approaches, which are inherently expensive and precludes adopting many innovative, inexpensive off-the-shelf solutions that are now available. But do all solutions need to be unique?

New Zealand’s healthcare sector is a breeding ground for IT applications, each DHB, conservatively, has 200-300 of them, and the larger DHBs have two to three times that. Therefore, the first step is to understand what the portfolio of applications across all DHBs and related entities looks like, then decide what to keep, what to consolidate, and what to replace.

Typically, the simplistic answer to these complex IT issues from business, and from many government agencies, would be: “You have to become more agile, scale better, achieve efficiencies. You have to migrate to the cloud and adopt more automation and intelligent tools.” But the response from health has often been – we can’t use cloud-based solutions because we have to protect patient privacy, or we have specialist solutions which are too complex, or we have too many legacy applications which can’t be migrated/upgraded. However, the New Zealand Government endorses hosting the majority of applications in public cloud solutions, and the Ministry of Health itself has adopted a cloud-based strategy for the majority (if not all) of its’ Covid-19 related systems.

So, if data privacy can be handled in a cloud context, I suggest the next key consideration, is the criticality of the system being evaluated. Specifically, New Zealand has geological features which make parts of the country seismically vulnerable. So, the question is, can you continue to provide robust and effective health services in a disaster, if this system is hosted in a public cloud? In many cases the answer is, a resounding “yes”. But in a small number of cases, probably not. I’m not advocating a rip and replace mindset, that clearly will not work. The health sector is the epitome of building a plane mid-flight, it requires a good deal of planning and assessment, but you have to start, and you should start with some sound outcome focussed principles.

One such principle is understanding that not all data is the same and knowing what can, and cannot, be hosted in the cloud allows you to identify areas where you can take advantage of cloud innovation, cloud economics and cloud geography, which in turn makes allocating budgets more manageable. But this requires flipping traditional approaches on their heads. As an IT leader, my suggestion is that your default position should instead be: “We should adopt a cloud first stance, but first let’s determine what we can and cannot do in the cloud – and why.”

The IT Fortress No Longer Exists

To maximise the benefits of cloud, businesses require clarity around which parts of their technology they need to be custom, configured, and generic. Then they leverage and adopt appropriate solutions aligned to that technology strategy. In the healthcare sector, you need strategic clarity around which parts of your business can adopt generally standardised services, or industry standardised services versus bespoke, all with an eye on securing the interactions between these systems. Most businesses adopt a hybrid-cloud approach to delivering business outcomes, having a combination of on-premise solutions, coupled with multiple cloud providers. The overriding need to protect patient data makes Health IT different from most other businesses, but it doesn’t mean that all applications need to be bespoke and locally hosted.

Cloud Principles to Follow

Here are three solid principles that will help you make effective decisions around your cloud strategy:

Proximity

Government healthcare organisations need to make sure technology and systems are in close proximity to where the data is needed, so that it can be quickly and reliably analysed for insights when patients seek treatment — whether in-person or over a video call — or when you are considering how to support patients in caring for themselves. Moreover, it’s important that patient information is also available to them in a form that they can both easily access and understand.

Sensitivity

It’s true that having local digital infrastructure gives the government, the healthcare industry, and individuals better control of their health data. But not all data fits this definition. Like healthcare, the military, intelligence and security, multinational consumer and retail, manufacturing, banking, and local and central government all work with highly sensitive data, which must be kept secure. They all have a strong focus on citizen and consumer privacy. And they all – or at least most of them — find ways to leverage cloud where appropriate.

Categorisation

In asking your clarifying question on what you can and cannot do in the cloud, I recommend you consider health systems under three broad categories:

• Mission critical systems, which without, the hospitals will fail to deliver any services. These should be treated like Industrial Control Systems and should live within the IT fortresses.
• Systems which need to share common information across the health sector. These are delineated as:
• Patient-related data, which naturally has a much higher hurdle for privacy and accessibility including controls allowing patients to decide who can access the data and from where.
• Operational data – stocking levels, perhaps even operating theatre and ward capacities.

These systems should live in a New Zealand based cloud service with appropriate disaster recovery contingencies. General admin systems, non-critical operational systems and other services can live in public cloud environments.

The resultant architectures and associated principles should be governed by the Health CIO group in a manner consistent with Enterprise Architecture standards, which inherently introduces opportunities for a continually evolving Health IT Enterprise Architecture.

Conclusion

I mentioned earlier that change is hard, but also possible. Some complexity comes from technology but in reality, the most complex part of this transformation will be changing the mindsets of the people involved. Medical staff, business administrators and IT professionals, must all come along on the journey. They will do that only when the proposed solutions are seen as responding to their needs and solving the questions that they ask. And for that to happen, you need people to start asking: ‘Why?’ – Why can’t we do this differently? What are the barriers to change?

So, let’s start by questioning the notion that the traditional fortress approach to Health IT is not the only answer. Honestly, it’s time to adopt a different – but no less secure – methodology.

About the author:

Greg Thomas is a Solution Executive at Unisys New Zealand. Greg has worked across many different industries and sectors over the past 20 years within the Asia Pacific region. He has designed transformational solutions for application, datacentre, cloud, and end user computing services, which have enabled businesses to modernise the way they deliver services to their customers.