The Irish Digital Health Leadership Steering Group (IDHLSG) is a community of over 65 Irish and international leaders (clinicians, patients, CEOs, Academics, policy makers) who have joined together to help lead the transformation of Ireland’s Health system through digital.
Recognising that the Health Service Executive, or HSE, as the Republic of Ireland's publicly funded healthcare system – which employs over 110,000 staff – and the Department of Health could not transform the health system on their own, a collaborative ecosystem-wide approach was created that has resulted in fast, cohesive and radical results.
Dr John Sheehan, radiology director at the Hermitage Clinic in Dublin and clinical vice-chair of the IDHLSG says: “I really think aligned public private healthcare and health tech, med tech, big tech and industry working together is such an exciting opportunity with so many benefits…..not reinventing the wheel, economies of scale etc… it completely gets you out of bed in the morning.”
In a country that has failed to deliver a national electronic health record in over a decade despite having an explicit strategy and the funding to do so, a unique, almost covert public/private collaboration has developed an architecture that could underpin the future digital health system of Ireland.
Prof Martin Curley presented a Leap Frog strategy to the HSE board in April 2020 that proposed the new Digital Health System should be focused around the patient and centred around a secure patient electronic health record. In addition to Curley, several other key leaders collaborated with one another in an digital transformation ecosystem: Dr Donal Bailey, innovation director of the country’s largest GP network; Eileen Byrne, CEO of Clanwilliam, the largest GP Practice software supplier in the country; Una Kearns, CEO of MyPatientSpace; and Dr Mohammad Al-Ubaydli, CEO of the world’s leading personal electronic health record.
The aim of this ecosystem was to create a working prototype instantiation of a digital health platform that could help move the point of care rapidly to the patient and the home. With further work, the potential is there to create an architecture that empowers patients, that is 10 times simpler and 10 times more productive than what exists today, and that could be 25 times cheaper than the 800 million originally touted as the cost of a National Acute EHR deployment.
Interoperability, security and privacy are critical, so these have been carefully considered. But, like all digital solutions, the HSE Digital Transformation iterates and tests the architecture in its living labs, improving it to ensure it acts as a platform that enables solutions meeting the SLSL quadruple aim – better outcomes, lower cost, better experience, better quality of life – as well as meeting SSFE criteria – Sustainability, Scalability, Security, Functionality and Ease of Use – while also meeting appropriate financial hurdles.
What has occurred here is an example of Open Innovation 2.0 (OI2) and what is called Architectural Innovation, where new, existing and emerging technologies are combined with knowledge to create a whole new product or platform with functionality that is far greater than the sum of the individual parts. Support from the HSE solicitors Philip Lee and HSE Procurement have helped create an environment where collaborative and co-funded innovation could be done in a safe fashion, while being fully compliant with procurement rules. The collaborative research and innovation work creates a prototype or minimum viable platform and an opportunity to learn what is actually needed before going for a national procurement. In contrast to the traditional waterfall model, this agile innovation process dramatically reduces risk and with clinician, administrator and patient involvement will result in a solution that actually meets all the user’s needs.
As with the intrduction of new paradigms and platforms, there may be strong pockets of resistance, but hopefully wisdom will prevail and opponents will recognise that putting patients in control of their data and empowering them will only lead to better outcomes, longer lives and lower costs. Taking an ‘honour the past and co-create the future’ approach will hopefully lead to a unified accelerated approach. Given the cloud-based nature of the solutions – and with the increasing support of the Irish digital minister Robert Troy – the digital health platform could be quickly scaled nationally, potentially making Ireland the first European country to reach the EU target of 90% of citizens having a personal electronic health record by 2030.
"The purpose of the HSE is to provide safe, high-quality health and personal social services to the population of Ireland. The vision is a healthier Ireland with a high-quality health service valued by all."
The goal of the IDHLSG is to accelerate and turbocharge this vision. Patient advocate and patient vice chair of the IDHLSG Gary Boyle says putting the patient first is critical, and he has worked with Zendra Health’s CEO, Thomas Coleman, to quickly build an app to support and educate the community of Parkinson’s patients in a country that has one of the lowest ratios of nurses to Parkinson’s patients in Europe. Prof Anthony Staines of Dublin City University and IDHLSG academic vice chair believes the key to the progress already made is the open collaboration attitude combined with the shared vision of ‘Stay Left, Shift Left’.
The presence of ‘heavyweight’ innovative clinicians in the IDHLSG such as Prof Richard Costello, who pioneered innovative digital respiratory solutions during COVID, and Prof Michael Sugrue, who is pioneering data-driven approaches to improving surgical outcomes, gives the IDHLSG real clinical credibility.
Recognising that the nursing community is the backbone of the healthcare system, the IDHLSG vice chair for nursing is Karen Kelly, an advanced nurse practitioner who modified a remote respiratory monitoring system into a heart failure remote monitoring system with outstanding results. Karen is also pioneering the introduction of the 10x Butterfly mobile ultrasound system into Ireland. Having respected leaders in the IDHSLG who buy into the economy of mutuality and value people and purpose as much as profit is creating very positive momentum and early promising results.
Transforming Irish healthcare with digitalisation leading the charge
Martin Curley is professor of innovation at Maynooth University, chair of the Irish Digital Health Leadership Steering Group and the director of digital transformation and open innovation at the HSE. Prior to joining HSE, Curley cut his digital teeth as vice president of Intel between 2009 and 2016, before bolstering his credentials by serving as senior vice president at MasterCard for a year, until 2018. According to Curley, he switched gears and put his skills to use in the healthcare industry to “transform the Irish healthcare system using digital".
"I firmly believe we can do it," Curley says. "Together with other leaders, we have been able to mobilise a national movement around radical digital transformation with tech, medtech, pharma, clinicians, patients and academics. We now have more than 50 living labs across the country. I've also written a book called Open Innovation 2.0, The New Mode of Digital Innovation for Prosperity and Sustainability, which discusses how to drive a structural change in industry using digital technology and an exponential innovation methodology.
"And the net impact of applying the method in the book is we're getting multiplicative and exponential outcomes rather than additive outcomes where we are seeing 10X better outcomes, 10X lower cost, and 10X higher volume. [Some people have called] this Curley's law. I'm not sure how I feel about that, but I've [been told to] just go with it."
One of these goals set to help Curley reform Ireland's healthcare system is to bring hospital services into homes via tech. Stay Left is about keeping well people well in their home or, if you happen to have a chronic condition or need rehab, the understanding that this can be done best of all from home.
"I am wearing a small device on my arm (from Waire) that can show you my real-time vital signs," he says. "This includes pulse rate, core temperature, oxygen saturation level and breathing rate, so the device is going to enable hospitals at home. In the future, it’s likely that many people will prefer to be treated in their home than being in a hospital. This will solve a really big problem in the healthcare system.”
In Ireland, the problem is particularly acute where acute hospital occupancy routinely runs higher than 95%. If planes ran at this level of utilisation, they would routinely fall out of the sky.
Curley argues that providing health monitoring systems closer to houses for personal use would "improve health" while "lowering costs". He then explained how technology could further be used to improve the global healthcare system.
"I think that it’s within reach," he says. “Using the internet of things, artificial intelligence, big data and cloud computing, we can make a real change ‒ one that hasn't been seen before."
Further to this, Curley also believes that current advancements in healthcare technology could increase general life expectancy by two-three years, every five years, for the next decade or so.
"We don't necessarily need to put more money into healthcare, actually," he says. "Digital therapeutics are a much more pivotal investment in terms of lifestyle and behavioural changes around nutrition and exercise. They're much more impactful. We recently created a living lab (Health Elevator) where you can get a health assessment, a personal electronic health record, and a wellness device all at the same time, and all for less than the price of a PCR test. This will enable us to walk the walk on wellness management, identifying risk factors earlier and reversing chronic diseases with assistance of digital therapeutics.
“We mobilised eight companies and services to work with us to create a new integrated health and wellness offering in less than two weeks. This is again what is called architectural innovation, integrating existing and emerging solutions and knowledge to create something. It's a very powerful type of innovation.”
Improving personal and population health doesn’t necessarily need more spend on clinical care but investments and improvements in lifestyle, nutrition, exercise, patient empowerment, diagnostics and smarter resource allocation.
According to Curley, HSE and the broader ecosystem aims to “empower patients and give them more self-control by testing solutions with patients as well as clinicians via its 50 living labs, ultimately providing people with closed-loop digital systems", for example such as the Medtronic 780G, which measures blood glucose levels in real time and adjusts insulin levels automatically directly via linked digital insulin pump.
The technologies incorporated in the labs are deemed by Curley to be engaging, empowering, educating and encouraging for patients.
"We're now expanding the Health Elevator living lab, first to 500, and then to 5,000 people ‒ for the price of just two to three cups of coffee per person!" he enthuses.
Together with John Shaw of Legato Health Technologies, Curley, in his role as Maynooth University Professor, set up the IDHLSG research working group to develop the Digital Health and Wellness Capability Maturity Framework. This grant was aided by IDA Ireland and Enterprise Ireland, while Medtronic, Roche, Cisco, and Huawei co-funded and supported it. A working group of executives, clinicians and patients meet monthly to build the roadmap, key interventions and measurements that will chart and guide Ireland’s progress over its digital health decade, towards being a global leader in digital health.
Ireland, in Curley’s eyes, is behind the rest of Europe in terms of healthcare, having jumped a maturity level from level 1 to level 2 in a 5 level maturity model, with COVID 19 acting as a big bang disruptor.
Shaw says: “We now have a 2025 digital capability because of the acceleration driven by COVID. Curley and Donal Morris, CEO of Redzinc, had a telehealth solution, Blueeye, co-designed and deployed in St James Hospital as well as in HSE Mental Health Services, before most of HSE mainstream employees had ever heard of Zoom or Teams.
"We have a very well supported national healthcare strategy, called Sláintecare, but the results delivery is lagging behind the vision, perhaps through overdependence on external consultants. I have always believed that strategy and accountability for delivery cannot be outsourced. All of the parties in the government approved the programme – which is unique in the history of Ireland – so while we are still lagging in Europe with respect to healthcare, we are on a fast improvement trajectory.
Sláintecare is a programme developed by the Department of Health of Ireland and HSE that aims to build equal access to services for every citizen, with its vision of one universal health service for all as a guide. With this new model, patients will be treated based on their need, instead of their ability to pay.
"We've now leapt from having a lagging respiratory measurement system to a world-leading capability with a company called PMD Solutions and their product, RespiraSense. RespiraSense is deployed in 23 acute hospitals and we have just now made it available in a community living lab setting. We're deploying vital signs automation to over 20 hospitals, detecting deteriorating patients earlier, improving the nursing experience, shortening average length of stays and adding new capacity back into the system through efficiencies.
The financial return is extraordinary, with an internal rate of return of about 1100%. The support of leading HSE clinicians such as Dr Mike O’Connor and Dr Siobhan ni Bhriain has been of huge importance, because, as Erik Topol famously said, ‘Medicine is remarkably resistant to change’. A strong clinical champion is the most important ingredient for success. Prof Colin Doherty, a consultant in St James Hospital, not only has been the sponsor for a new epilepsy EPR currently being built in an agile fashion with IBM and Salesforce, but has been the main co-designer.
“Together with major partner companies Centric Health and Roche, we have been able to reduce the rate of heart-related care home hospitalisations in one of the living labs by 10 times for patients with heart failure."
Patient responses to treatment within the living labs indicated that they felt "a lot more secure".
"They actually are monitored maybe a hundred times a year rather than eight," he says while adding that "the costs for the monitoring are reduced by a factor of two or three". Curley explains that the "overall strategy is about 'keeping well people well' in their home".
Tunstall Emergency Response and Irish based Pandu have developed a novel technology called a PanPan watch, which detects falls quickly and, within 20 seconds, connects the faller with a call centre in County Wexford and initiates two-way voice communication through the watch to see what help is needed. If the person is unresponsive, emergency services can be dispatched as the GPS locations are known. The PanPan watch allows 10 times earlier detection of falls, which has been shown to reduce average length of stay and, indeed, save lives. Already, 300 older Irish citizens are using the PanPan device in a distributed living lab.
T-Pro’s digital dictation solutions have now been adopted in every hospital group in the country, demonstrating a tenfold improvement in productivity, capturing speech in real-time, cutting out time waste and speeding time to treatment.
To be the best, you have to work with the best, and the HSE Digital Transformation team have forged strategic collaborations with ten global leaders, including: Microsoft, Medtronic, Dell, Cisco, Roche, Google and others. Additionally, Curley and his team are working with Enterprise Ireland to create ‘the first 25’ – a portfolio of 25 Irish Digital Health SMEs, such as Health Beacon, Synchrophi and PMP, with whom they have collaborated to bring value to Irish citizens, patients, clinicians and the overall system.
All of these companies have positioned their solutions to help support and accelerate the ‘Stay Left, Shift Left – 10x’ agenda. The collaboration with the British Embassy and the UK Department of International Trade has been particularly fruitful, with HSE Digital Transformation working with over 7 UK digital health startups.
Principle-centred leadership across the Irish health ecosystem.
According to Curley, Ireland has adopted a principle-centred leadership approach to the Irish Health Service’s Digital Transformation Innovation Plan, with the principles being "fundamentally important to the digital transformation” and having the potential to “maximise the success of digital transformation in Ireland'.'
Curley and fellow ecosystem colleagues such as John Sheahan (Blackrock Health), Brian Jordan (Cisco), Dr Donal Bailey (Centric Health), Prof Richard Costello (RCSI), Ronan Hurley (Medtronic), Maeve McGrath (Roche) and patient advocate Gary Boyle convened the Irish Digital Health Leadership Steering Group (IDHLSG) to oversee and orchestrate the digital transformation, using an all-of-Ireland and all-of-ecosystem approach. Curley drafted a set of 10 principles that were then reviewed, iterated and agreed upon by the IDHLSG, and then by the broader ecosystem.
Within this approach, there are ten core principles: "The first principle is to leap frog from being a laggard to being a leader. We want to move from a healthcare system that is paper-based, hospital-based, clinician and presence-based, to one that is patient-centric, in which remote monitoring is key and performed via cloud-based personal electronic health devices into a personal electronic health record."
IDHLSG’s campaign, ‘Stay Left, Shift Left’, fully realises the second principle. Where ‘Stay Left’ is about 'keeping well people well' in their own homes, ‘Shift Left’ focuses predominantly on “moving patients from an acute care setting, to a community one, to a home setting as quickly as possible”.
“All this can be achieved with different technologies and devices. With automated vital signs’ monitoring in a home, for example, we can allow early discharges post-surgery and perhaps more importantly enable a new Hospital at Home model,” Curley explains.
McKinsey predicts that by 2025, 25% of care currently provided in facilities such as acute hospitals could be performed in the home, with no loss of quality or access.
The third principle, Health 4.0, is the result of applying the principles of the currently evolving Industry 4.0 paradigm into a healthcare setting. Health 4.0 also revolves around patient engagement, patient empowerment, and patient encouragement.
The fourth principle revolves around “Open Innovation 2.0 (OI2), which is a leading-edge, innovative digital innovation methodology that identifies key design patterns that can lead to a structural change in an industry". Simply put, OI2 is about intensive networking and experimentation amongst high-trust partners aligned with a shared vision (Stay Left, Shift Left) and with the goal of creating a new kind of shared value incorporating increased wellbeing, welfare and wealth. Curley’s team member, Jim McGrane, runs a disciplined innovation management process to manage the various living labs, governed by an overarching digital solutions review board comprising senior clinicians and executives across the HSE.
Inspired by the "incredible exponential power of digital technologies", the fifth principle is what Curley calls, "10x radical innovation".
"We have been deploying digital technologies and healthcare settings. What we're finding from that is we are getting 10x better outcomes, 10x lower costs, and 10x volume increase," he says. A pattern is emerging and this could be codified in a new emerging ‘power law’.
The sixth principle, as Curley explains, is "a digital transformation pillar model". The model consists of five vectors, the first two of which concentrate on education. "We've created a digital academy and a Master's programme. We ignite the ecosystem using the digital academy forum, which has ‘TED Talks for Digital Health’," he elaborates. The other three pillars focus on using living labs to ideate, iterate and ultimately implement disruptive solutions.
He then explains that the seventh principle "is value-based healthcare". "We are building on the principles of the book by Michael Porter and Professor Elizabeth Teisberg, Redefining Health Care: Creating Value-based Competition on Results," Curley adds.
We move further to focus on value-based competition. A fundamental point of OI2 is that the unit of competition has moved from the organisation to the ecosystem and from the product to the platform.
“Our number eight is about dynamic capabilities and capability maturity for frameworks (CMF)," Curley says.
"So many healthcare organisations exhibited dynamic capabilities as a response to COVID, where they dramatically reconfigured themselves to enable mass-scale testing and mass vaccination – we need that same kind of agility once more in order to respond to opportunities effectively, which includes the legitimate transformation of healthcare through a digital approach. We use capability maturity frameworks as a way of organising how we sequence and prioritise solutions for implementation," he says.
Working with leading cardiologists, Prof Ken McDonald and Dr Matt Barrett, the IDHLSG research team have built: a digital cardiovascular CMF that identifies and prioritises key 10x interventions, such as AI-assisted echo tests; the Alivekor Kardia device for rapid, mobile ECG testing; and the Butterfly ultrasound device, which allows point of care ultrasound at high quality and is a lower cost than the current solutions. These solutions are targeted at constraints in the cardiovascular pathway leading to faster diagnosis, treatment and recovery.
The ninth principle argues that the digital health strategy should also be a cross-government and sector strategy with mutually reinforcing enterprise, sustainability and education goals. Curley and the IDHLSG work with many SMEs and multinationals to create new solutions which save and improve lives but also create growth and jobs through exports and also improve sustainability. Transport Minister Eamonn Ryan and Department of Enterprise Secretary general Dr Orlaigh Quinn have been particular champions of the cross Government approach to ‘Stay Left, Shift Left - 10x’.
The last principle is about using design thinking and design science research to envisage and create solutions that meet real needs and solve real problems. Curley’s team member, Des O’Toole, has built a repeatable design thinking process that is used at the front end of the clinical and patient engagement process.
To summarise this final principle, Curley utters the words that will always have a place in healthcare, regardless of the technological advances: “Empathy is key!”