eHealthNews recently interviewed general practitioner and Healthcare Advisor at MEDITECH SA , Dr Jacob Poo (pronounced Po), about his interest in Strategy and Policy in the public healthcare sector and his views on the future of eHealth and NHI in South Africa.

What’s your involvement in the South African health sector?

My focus is largely on the public health sector and my responsibilities at MEDITECH SA include managing the public sector account, client liaison at a strategic and political level, as well as long-term business sustainability.  I am also responsible for building relationships with the clinical end-users, especially doctors, as well as ensuring that our broad offering is in line with all requirements of the public health sector.

What’s the value of eHealth?

The answer is complex because eHealth is an interface between technology, health services, its delivery channels and the people who provide the service, and those intended to benefit from the service. The value of eHealth can therefore be defined from many different perspectives. eHealth is however not synonymous with the technology. Technology is merely an enabler and on its own rarely delivers full value.

Having said that however, there is no question about the importance of having real time access to an accurate, cradle-to-the-grave, comprehensive Electronic Health Record (EHR) of an individual patient at the point of care.

Continuity of care is a major challenge to patient care in the public health sector due to the lack of appropriate skill and resources, poor coordination and because of sheer patient volumes.  Effective eHealth solutions must therefore be able to support the continuum of care for their value to realised.  Not only must eHealth be able to capture and preserve clinical information but it must be able to present it intelligently enough that even the least experienced healthcare worker can understand it, spot danger signs and take action irrespective of which healthcare facilities the patient has visited.

Technology therefore becomes a platform upon which new treatment methodologies, patient referral systems, ongoing professional development programmes etc. can be implemented to achieve the desired patient outcomes in a predictable manner – even in settings with the poorest resources.

Can you provide an example of the scope and benefits of eHealth?

For example, eHealth is invaluable to epidemiology and the Integrated Disease Surveillance Response System. A national eHealth solution could provide accurate, detailed and verifiable demographic data but currently that data is held in separate locations and cannot be accessed as a whole. Seamless integration of the various datasets, coupled with the ability to monitor for indications of a likely disease outbreak and alert relevant departments and facilities in real-time, would allow us to respond immediately or even pre-empt epidemics in specific areas.

However, the ability to respond quickly to potential health threats is not only dependent on eHealth. The technology solution must be well aligned with the National Health Strategy on disease surveillance, outbreak response and people issues, such as skills and training. So for an effective Integrated Disease Surveillance and Response System, these components have to work well together to enable improvement in the larger response and intervention processes.

What are the differences between eHealth use in the public and private sector?

In general, the private sector’s use of eHealth focuses on eligibility to access private health insurance, billing and revenue collection. Efficiency is often assumed because of the availability of related services under one roof such as medical laboratories, radiology departments, well stocked pharmacies, etc. The key private sector concern is cost recovery and return on investment when adopting eHealth solutions. This is not necessarily negative though – they are valid questions bound to be asked in a highly regulated and competitive environment where profitability and long-term business sustainability have to be considered.  A combination of innovative policy measures and incentives could possibly spur the private sector into action when it comes to implementing expanded eHealth solutions.  Punitive measures for non-compliance are a possibility best left as a last option.

Currently, public sector eHealth initiatives tend to center around collection of data, the use of aggregated data for monitoring and evaluation as well as disease notification and management (HIV/TB). The public sector continues to grapple with quality issues, personnel shortages, the increasing burden of disease and limited financial resources. These are complex problems that cannot be resolved by technology alone.  Appropriate eHealth solutions however can enable the public sector to deliver predictable quality outcomes, reduce costly and unnecessary duplications, and provide reliable management information crucial to support planning and offering patients a better experience of health care.

Ultimately eHealth will have a large role to play in the public sector and, as the sector matures, I expect to see progress to accelerate steadily.

How can best practice be developed and shared among the South African eHealth community?

Governance, governance, governance. It’s crucial to effectively govern all areas concerned: IT, Clinical and Corporate. Getting to grips with governance along with issues such as clinical relevance and alignment to policy and strategy would form the basis for developing and sharing best practices stories.

However, people share experiences and not technology, so there must be room to experiment at provincial, district and local levels. Sharing will also only happen if it’s supported by the appropriate organisational culture and ethics. Fortunately, the issues around sharing information are understood in the industry and can be done without risking patient privacy and the confidentiality of their records.

Why has the introduction and uptake of eHealth initiatives been such a slow process in South Africa?

Largely due to the lack of leadership and a long-term strategy from the National Department of Health (NDoH), and the consequent lack of policy and regulatory framework. This is only now starting to change with the release of initiatives like the framework for interoperability in eHealth.

Secondly, inadequate or misallocated investment by the state has played a significant role in the adoption of eHealth initiatives. By the state’s own account, billions have been wasted on various poorly conceived eHealth initiatives. But a shortage of financial resources alone cannot explain our lack of progress in this regard.

There’s a lack of coherence between the provinces about eHealth implementation, and even within provinces. For example, different systems were implemented at different hospitals in the Free State. It was only an afterthought to agree on a province-wide EHR system. Added to that, a fundamental disconnectedness exists between various departments such as Health, Home Affairs, Communications, etc.

Lastly, the lack of appropriate legislative and policy framework to support the adoption of eHealth initiatives has resulted in policy makers being focused on Monitoring and Evaluation (M&E) systems whose entire dataset is aggregated.  This data is devoid of patient and clinical context beyond where the patient was seen and is easy to manipulate to create the impression of a well-functioning clinic, or hospital or even district. The data does not include comorbidities, identify missed opportunities or possible areas of clinical intervention, or aggregate clinical and non-clinical cost data. The rationale has been that detailed HIS systems are expensive and difficult to implement.  But the real cost of not having accurate and detailed, cradle-to-grave electronic patient records is that we are unable to quantify the success or failure of our interventions at a national level.

It is true that implementing sound eHealth solutions take time, money and a great deal of effort in policy review, and applying regulations and appropriate frameworks.  Thankfully this key ingredient for the adoption of eHealth initiatives is now being put in place.

What are your overriding views on NHI?

It is long overdue.  We can quibble about the details, but what is clear is that the current health funding model is unsuitable. NHI is very exciting and has huge potential.

One of the fundamental changes that NHI introduces is the requirement for District Health authorities to manage not just patients but deal with entire populations and the behaviour of each and every member of that population. This could be the health-seeking activity and patterns of a given population group, prescribing patterns of providers, clinical competence of an individual or group of clinicians and their ability to achieve pre-determined outcomes.

Lastly, what role does eHealth play in NHI?

eHealth is vital in NHI due to the level of complexity involved that cannot be managed manually. While the country has always punted preventative health care, one of the many benefits of NHI is that it provides a framework to start rewarding providers for promoting health and disease prevention, quality patient care and good clinical outcomes.  Simply put, NHI cannot be achieved without a system in place to provide real-time accurate, clinical information at the point of care.

One of the key responsibilities of the fund is to ensure sustainability and therefore, it has to enforce its gate-keeping role to prevent over servicing. In other words, it has to enable all providers to verify the eligibility of a patient for a specified set of services or procedures in real time, it has to monitor service level agreements with providers and suppliers, and be able to enforce/monitor compliance with defined clinical and administrative protocols, etc.

If lessons around the world are to go by, NHI or any health financing model for that matter, will without a doubt be plundered, fail to pay providers on time and fail to deliver the quality healthcare that all South Africans so desperately need without the infrastructure of a solid eHealth solution.

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