Health Report eolas magazine 2022

Health tech report

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Health information systems in Ireland New telecommunication equipment for telenursing at Health Sciences North, Horizon Santé-Nord (HSN) in Ontario, Canada.

In June 2021, the ESRI published Developments in health information systems in Ireland and internationally. The report’s objective was to provide a comprehensive overview of Ireland’s health information context and determine components of international healthcare systems that could be deployed in Ireland to enhance the existing healthcare system.

Omnipresent and dynamic challenges faced by the healthcare systems as a consequence of increased demand, increasingly complex requirements and the onset of the Covid-19 pandemic have combined to drive the development of HIS and enhance eHealth.

Since it became apparent that the Covid-19 pandemic required real-time interventions by healthcare decisionmakers, there has been a catalytic impact on the adoption of health technology. At the same time, the pandemic has provoked significant public engagement with health data, potentially acting as an impetus to sustain public buy-in and increase investment in a modern HIS and health data collection.

Cognisant of the broad scope of health information systems (HIS), eHealth and health technology, the authors of the ESRI report, Brendan Walsh, Ciarán Mac Domhnaill and Gretta Mohan, 88

homed in on components which are most pertinent to policymakers in an Irish context.

As such, its HIS report explored three core areas: 1. characteristics of successful international health information systems; 2. Ireland’s health information system and the health data context; and 3. telemedicine deployment during the pandemic.

Characteristics of successful international HIS In order to establish a framework with which to view and understand Ireland’s current HIS context, the ESRI sought to explore and record key features of international HIS. In doing so, several commonalities were discovered among effective HIS.

The first commonality is the national deployment of an individual health identifier (IHI). In Scotland, for instance, the Community Health Index (CHI) uniquely identifies individuals on a national register which is incorporated in numerous electronic medical recording systems in the NHS Scotland system.

The second commonality is the creation of a national electronic health record (EHR). EHRs enable information to be coherently linked between different components of a healthcare system.

Interoperability between healthcare data systems is essential to unlocking the optimal benefits of health informatics.

For example, the NHS Spine database in England links healthcare IT systems across services and providers, facilitating the secure sharing of information as per its eReferral Service.

Similarly, during the pandemic, New Zealand’s National Health Index (NHI)

by the pandemic, Ireland’s public health data infrastructure is inadequate.

Added to this is fragmented public and private healthcare provision.

was linked to EpiSurv, the country’s Covid-19 case database.

The third commonality is the ability of different components with a health system to interact and integrate with each other. In the absence of this ability, the use of EHRs, big data and health technologies are restricted.

Decentralised health systems, such as the Canadian model, or countries with several systems that cannot be integrated, such as NHS England, illustrate that a robust HIS with interoperability requires an holistic view of the health system, both public and private.

The final commonality is the instillment of confidence among data subjects, or the population as a whole, that data is collected for a specific purpose and stored safely and securely. Modern HIS can empower patients utilise their data to inform data-based decision-making about their care pathways. Likewise, telemedicine has ensured that patients were able to access care remotely, lessening the unmet need for healthcare during the pandemic.

Irish context Developments in health information systems in Ireland and internationally demonstrates significant disparities in HIS, health data infrastructure and the deployment of health technologies across Ireland’s healthcare system. At the most basic level, and as exposed

The ESRI report identifies several areas within the Irish healthcare system within which there are omissions in the recording, collection, and collation of patient data, particularly in relation to healthcare utilisation and expenditure.

As a result, for example, in the absence of IHIs, the HIPE dataset cannot track accompany patients between hospitals.

In the private sector, providers offer insufficient insight into the total care and types of care that they undertake.

This acts as a barrier to the development of a comprehensive and resilient HIS in Ireland.

However, the adoption and integration of eHealth solutions gathered some momentum. For instance, eReferrals and ePrescriptions are now established components of the Irish healthcare system. The Irish National Epilepsy Electronic Patient Record and the Electronic Patient Record (EPR) have transformed care pathways and enhanced contact between patients and clinicians. This acts as a template for further expansion to wider patient populations in the pursuit of a national EHR. Once this is established, as illustrated by England’s OPENSafely platform, data analytics platforms can deliver insights for patients, clinicians, and policymakers to help plan and deliver improved care.

Telemedicine The pandemic has also had a disruptive impact on engagement with the healthcare system. As a result, telemedicine has rapidly established itself as a central pillar both of healthcare in Ireland and beyond.

Telemedicine consultations are now occurring almost as regularly as inperson consultations in both primary and acute care settings. Figures

Amid this swell in digital health, a considerable challenge exists in relation to the security of personal data. The Council of Europe acknowledged this in its Digital solutions to fight Covid-19 report in which it notes: “The quantum leap in the digitalisation of our lives requires that measures adopted by governments during the health crisis uphold the protection of individuals with regard to the processing of personal data.” To this end, data protection will be the constituent factor in delivering patient trust in digital healthcare solutions. This will, to have some degree, been undermined by the recent HSE data breach in which a cyberattack exploited vulnerabilities to expose patient data in an attempt to extract a ransom payment.

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Therefore, as acknowledged by the HSE leadership in 2016, the adoption of an IHI and national EHR could transform the Irish healthcare system.

The creation of eHealth Ireland was a fundamental component of the HIS journey in Ireland. Between 2018 and 2021, capital funding for ICT projects has doubled to €120 million. At the same time, less than 0.8 per cent of the €20.62 billion health budget for 2021 will be allocated to eHealth and ICT.

emerging from NHS England indicate that the proportion of telemedicine consultations has increased from 14 per cent to 40 per cent since the onset of the pandemic. While the data is less complete in Ireland, the Irish Medical Council has indicated that similar increases have occurred.

Conclusion Informed by its findings, the ESRI report outlines six key policy recommendations relating to HIS, health data infrastructure and health informatics. These are: 1. that a national HIS is developed, leading to the comprehensive adoption of the IHI and a national EHR across both the public and private healthcare systems; 2. that health data infrastructure be robust, structured and rigorous, encompassing data from both public and private providers; 3. that data protection and cybersecurity measures are aligned with relevant legislation and the GDPR; 4. that investment in current and capital ICT and eHealth be continued; 5. that digital health literacy be enhanced to ensure that the public, including vulnerable cohorts, understands the benefits of eHealth and can access eHealth services; and 6. that the healthcare workforce is acknowledged as fundamental to the successful integration of a HIS. 89

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What can we learn from the HSE and Department of Health ransomware attacks?

Ireland appeared to be shaken to the core by the recent cyberattack on the HSE and the Department of Health, but once past the initial shock, it is time for an in-depth look at the Irish cybersecurity infrastructure and whether such attacks could not have been anticipated, detected, or prevented.

In 2017, the National Health Service (NHS) in the United Kingdom came to a standstill because of an attack by the notorious WannaCry ransomware that paralysed their computers. The recovery was long and cost the NHS £92 million, but were any lessons learned on this side of the Irish Sea? Let’s have a quick look at the details we know and how the matters could have been handled differently.

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It has been reported that 700 gigabytes of the HSE’s data was allegedly exfiltrated by the cybercriminals. Given that the data is stated to be of a sensitive nature, content aware data leak prevention (DLP) could have been useful in preventing the movement of such data. Content aware DLP software aims to prevent intentional (and accidental) leakage of sensitive data by first identifying the data (using some rules written by the administrator) and then controlling who can access the data, how they can interact with it (and when), and where it can be moved.

The utilisation of a cloud sandboxing 90

solution can also be effective in combating ransomware infections and zero-day threats. A properly configured cloud sandboxing product will temporarily pause the execution/opening of any unknown files until they are analysed in an operating system in the cloud. If a file is found to be malicious, execution is stopped and the file removed, with detections being provided to all the other endpoints on the network. If the file is benign, it will be allowed to run. Sometimes the most effective way of detecting what a piece of unknown software will do is to simply let it run and monitor its behaviour. It’s obviously too dangerous to do this on protected network hence the utility of cloud sandboxing solutions.

Given that the reports suggest the attackers “lived” in the network for approximately two weeks, it must be asked if the HSE's security team were utilising an endpoint detection and response (EDR) solution. EDR products aim to detect the movement and actions of attackers in a protected network by

reporting seemingly innocuous events to security teams for analysis. Things like the commands they would have run, the files they would have changed, the login attempts they would have made, etc.

These actions when flagged by a proper solution should ring alarm bells for any security operation centre analyst and trigger an immediate investigation. In short, a correctly configured EDR solution would have flagged events typical with lateral movement to analysts.

ESET Ireland continuously stresses the importance of a thoroughly planned defensive posture and a multi-layered approach to cybersecurity. While there is no such thing as 100 per cent security, by applying comprehensive preventive measures, the bar can definitely be raised to an extent that makes it a lot harder for cybercriminals to carry out major disruptions.

ESET Ireland T: 053 914 66 00 E: info@eset.ie W: eset.ie

WHO publishes its global digital health strategy health tech report

The World Health Organisation (WHO) has published its Global Strategy on Digital Health 2020–2025 as it looks to “improve health for everyone, everywhere by accelerating the development and adoption of appropriate, accessible, affordable, scalable and sustainable person centric digital health solutions”.

The publication of the strategy marks an end to a long process that began with the 2005 resolution on eHealth that urged WHO member states “to consider drawing up a long-term strategic plan for developing and implementing eHealth services… to develop the infrastructure for information and communication technologies for health… to promote equitable, affordable and universal access to their benefits”. In the meantime, further resolutions had been passed at WHO level and passed by the United Nations and World Health Assembly. A draft digital health strategy covering 2020-2024 was initially published in the summer of 2020, but the strategy proper has now been published.

The strategy states that digital health will be adopted if it “is accessible and supports equitable and universal access to quality health services; enhances the efficiency and sustainability of health systems in delivering quality, affordable and equitable care; and strengthens and scales up health promotion, disease prevention, diagnosis, management, rehabilitation and palliative care including before, during and after an epidemic or pandemic, in a system that respects the privacy and security of patient health information”. It is recommended within that adoption of digital health technologies be a component of any national strategy, although it is acknowledged that this will be a challenge, especially in low- and middle-income countries. Member states are advised that exploring the potential of global solutions should be a part of their national strategies.

The purpose of the strategy is “to strengthen health systems through the application of digital health technologies for consumers, health professionals, health care providers and industry towards empowering patients and achieving the vision of health for all” and it emphasises that “health data are to be classified as sensitive personal data, or personally identifiable information, that require a high safety and security standard”.

The strategy is guided by four principles: 1. “Acknowledge that institutionalisation of digital health in the national health system requires a decision and commitment by countries”: Each country owns its digital health action plan built on the strategy within its own national context and should adopt digital health in a way that is “sustainable, respects their sovereignty, and best suits their culture and values, national health policy, vision, goals, health and wellbeing needs, and available resources”.

2. “Recognise that successful digital health initiatives require an integrated strategy”: Member states should be aware that for digital health initiatives to reach their potential, they should be “part of the wider health needs and the digital health ecosystem and guided by a robust strategy that integrates leadership, financial, organizational, human and technological resources and is used as the basis for a costed action plan which enables coordination among multiple stakeholders”.

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3. “Promote the appropriate use of digital technologies for health”: The strategy “underscores the need to ground digital foundations within national strategies and emphasises the need to work with different sectors and stakeholders at all levels” and states that the “appropriate use of digital health takes the following dimensions into consideration: health promotion and disease prevention, patient safety, ethics, interoperability, intellectual property, data security (confidentiality, integrity, and availability), privacy, cost-effectiveness, patient engagement, and affordability”.

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4. “Recognise the urgent need to address the major impediments faced by leastdeveloped countries implementing digital health technologies”: There is a “pressing need” to engage with and invest in the issues developing nations face in engaging with digital health, such as “an appropriate enabling environment, sufficient resources, infrastructure to support the digital transformation, education, human capacity, financial investment and internet connectivity”.

These four principles then inform the four strategic objectives of the strategy: 1. Promote global collaboration and advance the transfer of knowledge on digital health: Member states are instructed to share their knowledge of and investments in digital health across domains in order to align countries strategically. The policy initiatives recommended to achieve this goal include the establishment of mechanisms for strengthening national digital health strategies and implementing key collaborations, the establishment of a knowledge management approach to identify and share good practices and the supporting of countries in establishing information centres for disease surveillance.

2. Advance the implementation of national digital health strategies: Under this objective, the WHO aims to “stimulate and support every country to adopt or review, own, and strengthen its national digital health strategy” through defining a national digital health architecture blueprint or roadmap and adopting opensource health data standards, while aiming for reusable systems or assets including interoperability of health information systems both at national and international levels.

3. Strengthen governance for digital health at global, regional and national levels: The WHO is seeking to strengthen the governance of digital health at local and international levels “through the creation of sustainable and robust governance structures”, including regulatory frameworks. Under this goal, the WHO calls on its member states to “coordinate investments in evidence-based approaches to assess promote and disseminate new and innovative health technologies for national scaled digital health programmes using a person-centred approach to facilitate actions and investments based on informed decisions”.

4. Advocate people-centred health systems that are enabled by digital health: This objective “advances digital health literacy, gender equality and women’s empowerment and inclusive approaches to adoption and management of digital health technologies” and “places people at the centre of digital health through the adoption and use of digital health technologies in scaling up and strengthening health service delivery”. This is to be achieved by developing approaches to the management of health at the population level through digital health applications that move health and well-being from reactive-care models to active communitybased models, reducing the burden of data collection from front-line workers by reorienting reporting-based tools into service delivery tools and establishing, monitoring and evaluating models to facilitate the contribution of digital systems to health system processes.

The WHO says it will take steps to implement a measurement model to evaluate the action plan and the stated set of outputs in collaboration with national centres, the Sustainable Development Goals and the goals of WHO’s Thirteenth General Programme of Work, 2019–2023. They state that the establishment of a monitoring and evaluation framework that promotes a biennial enhancement of the global digital health strategy is “also warranted”.

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Medical devices regulation and create fair market access for manufacturers.

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Speaking as the regulation came into force, Stella Kyriakides, European Commissioner for Health and Food Safety, said: “This is an important step forward for the protection of patients across Europe. The new rules improve the safety and quality of medical devices while providing more transparency for patients and less administrative burden for businesses.

The legislation will strengthen innovation and our international competitiveness, ensuring that we are ready for any new and emerging challenges.”

Credit: Tom Claes

Separately from the MDR, a regulatory framework applicable to in vitro diagnostic (IVD) medical devices is set to come into force on 26 May 2022. In vitro diagnostic medical devices are used to perform tests on samples, include HIV blood tests, pregnancy tests, Covid-19 tests and blood sugar monitoring systems for diabetics.

In May 2021, a year later than scheduled, stronger rules on medical devices were introduced across the EU. The Medical Devices Regulation (MDR) was politically agreed across the EU’s Parliament, Commission and Council in May 2017 and was set to become fully applicable in May 2020 following a three-year transition period. The outbreak of Covid-19, however, saw a 12-month delay imposed on the application as device manufacturers turned their attention to addressing the challenges posed by the pandemic.

The MDR became fully applicable on 26 May, 2021 and represents a strengthening of the existing regulatory system for medical devices across Europe and a replacement of the original directives which had been in place for some 25 years. As a regulation, rather than a directive, the MDR is directly applicable at national level, without the requirement for transposition through national legislation, enabling greater legal certainty and preventing variation in the 94

rules relating to medical devices across member states.

The regulation covers over 500,000 types of medical devices on the EU market, ranging from hip replacements to sticking plasters. Medical devices are defined as those that have a fundamental role in saving lives by providing innovative healthcare solutions for the diagnosis, prevention, monitoring, prediction, prognosis, treatment or alleviation of disease.

It does not overwrite the fundamental components of the current regulatory systems but aims to strengthen them through addressing identified gaps or weaknesses and gives consideration to technological and regulatory developments in the medical technology sector.

At its core, it aims to increase transparency, improve clinical safety

The three main aspects of the MDR, for which the National Standards Authority of Ireland is the sole notified body (subject to supervision by the Health Products Regulatory Authority) in Ireland, are: Quality, safety, reliability and improvement: Tighter controls are imposed on high-risk devices, such as implants, and consultation of a pool of EU level experts is required before devices are placed on the market.

Additionally, clinical evaluations, investigations and the notified bodies that approve the certification of medical devices will be subject to tighter controls; Strengthens transparency and information: Vital information for patients will be easier to find with the European database of medical devices (EUDAMED) containing information about each medical device on the market, including economic operators and certificates issued by notified bodies. Additionally, each device will have a unique device identifier, to make sure it is findable on the database; and Enhance vigilance and market surveillance: Manufacturers will be required to collect data about the devices’ performance once it is on the market and member states will improve coordination on vigilance and market surveillance.

Three pillars of digital transformation

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departmental structures. This delivers cost savings and improved patient experience through efficiency. By adding artificial intelligence and robotic process automation we can also remove the mundane work and reduce error rates leaving your staff free to deliver the real value-added services, those that need a human touch. Our experience has been that staff who are impacted by this type of change experience an increase in job satisfaction, patient satisfaction increases, and complaints go down.

Low code platforms enable digital transformation

Public service is more proactive in digital transformation than people think and typically uses three key pillars for change writes Peter Rose, CIO of TEKenable.

The advent of Covid accelerated the need for digital transformation across the public and private sectors where there was already a fast pace of change. We have worked with the HSE delivering contact tracing and the PPE ordering system (amongst others) but even before Covid, TEKenable worked with Dublin City Council to deliver Voter.ie, providing online registration to vote, with An Post to deliver Ad Mailer, a digital transformation of postal advertising campaigns and Mayo County Council to streamline recruitment, all based on the three pillars below.

If you are still requiring paper forms, you are accepting the responsibility and cost of correcting the inevitable errors and omissions. Providing online selfservice capabilities to your patients/staff is a “no-brainer”. It ensures data quality at point of entry eliminating the chase processes that are required to deal with errors on paper forms and enables the end user to engage at their convenience. We refer to this approach

Pillar Two: Customer engagement CRM is a bit old hat now; customer engagement is the new gun in town.

Create an omni-channel communications hub including bots and personalisation, centralising customer data, integrate it with a workflow layer that spans siloed IT systems and crosses departmental boundaries, and you will deliver an optimum experience.

Customer-facing staff will have full visibility of the customer and managers a full view of the processes and any bottle necks.

Pillar Three: Back-office process automation

We use low code platforms such as Microsoft’s Power Platform in conjunction with the power of the Azure cloud to tackle in-depth and complex challenges, making application development much more efficient, flexible, and responsive to change.

Dynamics 365 and Power Platform from TEKenable can deliver Self-Service with Customer Engagement, can support back-office Process Automation and apply Advanced AI and RPA to improve efficiency with much of this not needing to be built, it is out of the box.

Talk to us if you are interested in seeing what can be done when you have the right tools!

Peter Rose TEKenable Ltd – Harmony Court, Harmony Row, Dublin 2 peter.rose@tekenable.com +353 87 271 2660 www.tekenable.ie

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Pillar One: Self-service

to data quality as: “Clean the river, not the lake.”

With major change programmes commencing in many government departments, local authorities, and the public sector in general there is a key differentiator between success and failure, the IT tools used to deliver that change.

The Self-Service pillar removes some non-value adding processes from the back office, but it is not the full story.

Building on the customer engagement layer, back-office processes can now also span the artificial boundaries created by legacy IT systems and 95

Credit: Bermix Studio

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Irish health tech statistics Ireland is a base for a thriving health tech sector, with collaboration between industry, third-level institutions and government constituting one of its key attributes. Today, it is one of Europe’s leading medical technology centres.

More than 300

medical technology companies are based in Ireland 70% of these companies are engaged in R&D

¹⁴⁄ ¹⁵

of the world’s top medical technology multinationals have operations in Ireland 96

38,000

Irish people are directly employed by medical technology companies Alongside Switzerland, Ireland is second only to Germany in terms of the number of people per capita employed in Europe’s medical technology industry health tech report

€12.6 billion

Total value of Ireland’s medical technology exports This represents 8% of Ireland’s merchandise exports

2nd largest

exporter of medical technology products in Europe

33%

of the world’s contact lenses are manufactured in Ireland

80%

of global stent production occurs in Ireland

Over 30 million

75%

of orthopaedic knee production occurs in Ireland

people with diabetes use Irish-made injectable devices

This is over 25% of the global population of people with diabetes Source: IDA 97

Virtual health: The next frontier

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leaders also cited remote monitoring as a key area for future investment. Prior to the pandemic, McKinsey “found that health systems, under value-based care arrangements, demonstrated 17 per cent savings when they provided virtual care with their existing healthcare professionals instead of using an outsourced provider”, showing the opportunity that exists for providers to embrace the technologies from both a modernising and a financial standpoint.

Particularly relevant to the Irish context could be the opportunities that exist to promote efficiency through models like tele-ICU and change-capacity use through “hospital at home” (HaH) models. Examples of models cited by McKinsey that could be of use in rural Ireland where access to speciality services is scare include:

As automation comes to the fore of daily life and the Covid-19 pandemic leaves healthcare providers looking for alternative methods to deliver treatment, boost quality of care and decrease spending, virtual health strategies may begin to become a more common mode of healthcare delivery.

Virtual health has long been heralded as the next breakthrough in health technology, but its adoption has varied between slow to non-existent from country to country. Virtual health can be broadly broken down into three categories: telehealth, digital therapeutics, and care navigation.

These categories further break down into subcategories such as synchronous and asynchronous telehealth, remote patient monitoring, replacement therapies, treatment optimisation, patient self-directed care and e-triage. Commonwealth Fund research showed that adult primary care and behavioural health showed smaller declines in total visits during the pandemic than surgical/procedural specialties.

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These smaller declines illustrate the fact that primary care and behavioural health visits can be accomplished by evaluation and management only as opposed to surgical specialities. Such differences in specialities suggest that opportunities are there for the further rollout of virtual health technologies, such as remote monitoring, which could allow both primary care and specialty care practices to expand their virtual patient interactions.

A pre-pandemic survey of health system leaders performed by McKinsey and Company in 2019 revealed that “virtual health adoption was highly concentrated in synchronous telemedicine, with limited investment in the full suite of available virtual health technologies”. These health system

•

a regional health system that provides virtual specialist visits and tele-ICU coverage in partnership with local rural health systems to extend access to services;

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a regional health system that partners with a third-party provider of virtual primary care to extend its primary care capacity and creates linkages to its specialty practices;

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an academic medical centre (AMC) that provides virtual specialty care that consumers access directly from different geographies, with some consumers choosing to travel for care; and

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a regional health system that provides primary and specialty care through physical and virtual applications, and partners with an AMC to access virtual sub-specialty care.

The HaH setting in particular could be of significant benefit in Ireland, where an ageing population can often be matched with rural isolation, meaning that the implementation of HaH could mean both a reduction in travel for many patients and a reduction in healthcare-associated infections.

Covid-19 has prompted much talk of a “new normal”; in healthcare, it appears the time is ripe for the new normal to incorporate the disruption that has been talked about long before the outbreak of the pandemic.

Leveraging new technology to deliver responsive nursing and midwifery regulation

At NMBI we are leveraging new technology to continue our important work as a regulator, in the face of a global pandemic, while also progressing our digitisation and modernisation agenda to adapt to the evolving needs of the health sector. As we hopefully emerge from the worst of the pandemic it is time to build on what we have done best during the height of the crisis, and we are now using new technologies and better ways of working to create a more agile and responsive regulator.

The role of NMBI As the regulator for nurses and midwives in Ireland, our mission is to protect the public and the integrity of the professions of nursing and midwifery.

We focus on three areas specifically: • Publication and maintenance of the Register of Nurses and Midwives and the Candidate Register; • Education standards and requirements; and • Complaints about the practice or behaviour of a nurse or midwife.

Using technology to modernise

Fitness to practise As the regulator, NMBI is legally responsible for considering complaints against nurses and midwives who

This change, using new technology, was born out of necessity but has proved beneficial. Now that restrictions have eased, we are keeping the best of what we created to help improve the way we work. A hybrid approach is being taken to inquiries, with some participants physically present and others participating online.

hard to address these and to ensure that we learned from them. I am confident that over time the benefit of digitisation will significantly outweigh the teething problems experienced.

NMBI is on a journey to becoming a more efficient and effective regulator and new technology is enabling us to better deliver on our mandate of upholding the high standards of nursing and midwifery in Ireland and ensuring

Education Our education team is using new technology to evolve the way they work and ensure they are more agile, carrying out virtual site inspections. These are proving successful, and more are planned.

public safety.

E: communications@nmbi.ie W: www.nmbi.ie

Registration New technology is also driving change in our registration process. In the past year we have broken new ground with the launch of our digital platform MyNMBI. We were the first healthcare regulator to digitise all of our registration processes, allowing registrants to avail of a range of services online and leading to the collection of better data.

As with all new technology there was a bedding-in period and there were some user-experience issues at the outset of this new system, but our teams worked

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NMBI is on a journey to provide a more modern, responsive, and agile model of service provision and regulation.

Technology is central to this journey, and I believe it is important to embrace it and use it to drive positive change and allow us to work better together in new ways.

practise in Ireland, to ensure the protection of the public and the safeguarding of confidence in the nursing and midwifery professions. The pandemic brought a halt to the running of onsite/in-person inquiries. Our fitness to practise team responded quickly.

Online inquiry solutions were identified, tested, and rolled out, after engaging with those involved. Since December 2020, 17 inquiries have concluded in online or in hybrid form, over 37 inquiry days.

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These are times of both change and challenge, for the health sector and for NMBI, and the way in which we respond will define our future, writes Sheila McClelland, the CEO of the Nursing and Midwifery Board of Ireland (NMBI).

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Realising the benefits of eHealth is not simply a technological endeavour, a new report into the social and ethical implications of eHealth policy in Ireland by the Oireachtas’ Library and Research Service states.

Unlocking the potential of eHealth solutions requires “careful attention to the interdependencies between people, process and technology”, the report, written by Tim Jacquemard, Royal College of Surgeons in Ireland and Science Foundation Ireland researcherin-residence, states. Published in March 2021, the report says that eHealth solutions are “often complex, largescale projects with significant economic, social and ethical implications” and that “a failure to address these interdependencies can lead to undesirable outcomes, such as privacy breaches, wasted monies and project collapse”.

Through its examination of Irish eHealth legislation, its implementation by governmental and non-governmental bodies and case studies such as the

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Covid Tracker App, the report identified 10 policy issues for eHealth in Ireland.

1.

Irish policy and debate consider eHealth to be a critical enabler of healthcare reform

Activity around eHealth in Ireland is constantly growing, and public debate “ascribe[s] eHealth the ability to transform the Irish healthcare into a more patient-centric, integrated and cost-effective system. The Programme for Government, Sláintecare, and the National Development Plan all make specific mention of eHealth, while the past 10 years have seen the partial rollout of a number of initiatives, such as the individual health identifier and ePrescribing. Other national projects

which will provide the basis of national eHealth in the decades to come, such as the national health record, are said to be “under development”.

2.

A failure to identify and address social and ethical implications can impact the success of eHealth technology

The report states that among the factors that determine the success of successful eHealth applications are “the social and ethical values of stakeholders, their organisations, and the cultural and political context”, meaning that the social, political and ethical values that are important in the Irish context must be factored in when

designing these applications. A failure to do so “may lead to public backlash, lost investments or suboptimal functioning of the technology”. The social and ethical implications of eHealth “can be considered at the earliest stage of technology development” and “can help guide the design, development, implementation, and use of the technology”, the report states.

“The research performed by Jacquemard ‘found no

3.

The benefits of eHealth discussed in Irish policy fit with the “quadruple aim” method of improving healthcare by improving individual experience of care, improving the health of populations, reducing the per capita cost of care for populations and improving the clinician experience of care. The discussion on eHealth and health improvements in Ireland “aligns closely with a more contemporary understanding of health as a person’s ability to adapt and to self-manage”. Benefits for clinicians are said to be mentioned less frequently.

The report identified seven clusters of ethical and social challenges and opportunities in relation to eHealth: privacy; equality; human relationships; patient empowerment and vendor relationships; benefit and risks; responsibility; and transparency and trust. All seven clusters “include both opportunities to achieve socially and ethically desirable outcomes as well as challenges to avoid undesirable outcomes” with identification of benefits and risks critical to the success of these projects.

4.

This research found no systematic approaches to address ethical and social implications of eHealth within Ireland

Worryingly, the research performed by Jacquemard “found no systematic approaches in Irish policy to address the ethical or social implications of eHealth”. He suggests that either the HSE or HIQA would be well-equipped to lead in this area.

5.

Ethical values are not explicitly mentioned in Irish policy on eHealth

The research also found there to be no explicit mention of ethical values in Irish eHealth policies, with such ethical values left to “only appear implicit within Irish policy and debates around eHealth”.

6.

Irish policy and debate emphasise benefits for healthcare improvement

ethical or social implications of eHealth’. He suggests that either the HSE or HIQA would be well-equipped to lead in this area.”

7.

Other clusters of social and ethical opportunities are mentioned less frequently in policy documents and debates on eHealth

While the report says that the issues covered in the Irish debate around eHealth are pertinent, it also states that “other relevant benefits exist”. The questions Jacquemard suggests to be considered are: “how can eHealth improve the work experience of clinicians?”; “how can technology improve the relationship between clinician and patient?” and “how can eHealth make communication more secure?”

8.

Irish policy and debate emphasise challenges associated with privacy and data protection

Perhaps understandably given what has transpired since the publication of the report in March, Jacquemard says “the challenges mentioned concern mostly privacy and data protection” in the Irish context of eHealth discussions, unlike at EU level, where the challenges of eHealth itself are the focus. The report warns that “reducing ethical and social concerns to privacy and data protection can lead to suboptimal technology, as eHealth presents a wider range of ethical challenges”.

9.

Many of the social and ethical opportunities in Irish policy leave room for interpretation

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eHealth offers many ethical and social opportunities and challenges

systematic approaches in Irish policy to address the

The report states that the “ethically and socially relevant benefits and challenges mentioned in policy are general aims and objectives”, which means that the “high level of abstraction leaves the ethical and social opportunities open to interpretation”.

One example cited is that the eHealth Strategy for Ireland makes mention of the digital divide but does not elaborate on how eHealth might help to bridge that divide, and that the divide is not mentioned in the eHealth section of Sláintecare. Questions in this are to be considered, Jacquemard suggests, are: “Which parts of the population will gain better access and who will benefit the most?”; and “how will people who lack the requisite digital and health literacy skills be supported?”

10. Irish eHealth policy focuses mainly on policy for health services devices Irish “eHealth policy is focused on health service reform: the technologies emphasised in the policies reflect this focus on service reform”, with the technologies discussed in the Irish context, such as electronic health records, ePortals, telehealth, and ePrescribing, aimed at improving relations between health service providers and patients. The report notes that EU health policies “tend to focus on consumer technologies as well, such as mobile health, social media, and wearable devices”. With consumer technologies now so ubiquitous, the report states that the “HSE may increasingly integrate consumer apps, for example videoconferencing for telehealth”.

Healthcare organisations and consumers need protection against inadequate technology, Jacquemard says, noting that “apps may contain disinformation, lack security updates, or show poor regulatory compliance”.

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Credit: Ani Kolleshi.

health tech report

Pandemic-driven health tech The outbreak of Covid-19 drove rapid rollout of technology-led care provision, necessitated by a need to offer digital-first care solutions.

Historically slow to adopt new innovations at pace, healthcare has for a long time been recognised as an area in which technology could drive greater efficiencies and outcomes. However, a number of notable barriers have stood in the way of integration of digital solutions, not least, regulatory barriers, an unwillingness to modify and collaborate existing systems and cost.

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delivery, has altered that mindset. In fact, experts assess that such was the extent of the boom in health tech innovation over the past year and a half that progress is now irreversible and will form a basis for greater innovations in the near future.

While the potential benefits of things like telehealth, data-driven diagnostics, and augmented reality (AR) are well known, the rigid structures of the health service and the scale of the transformation required, led many to accept that the pace of integration of health tech solutions at scale would be slow.

Two distinct trends have underpinned much of the current innovation. The first is a change of culture. The Covid-19 response required unprecedented levels of flexibility and cemented the role of technology within the sector as an enabler. Where previously health tech innovation had to slowly navigate preventative structure and barriers, historic hesitancy of innovation adoption was reversed in favour of speedy deployment and fresh agility.

The pandemic and the subsequent response, including rapid deployment of health tech solutions to address the much-changed landscape of service

A second key trend was a more structured move to demand-led health tech solutions. Health tech companies had a greater understanding of the

challenges facing the health service and worked to deliver solutions to real-time problems. Recognition of immediate benefits to technology adoption has aided the willingness of the sector to integrate these new innovations.

As a result, much of the technological innovation has tended to focus on new applications of artificial intelligence (AI) and data platforms, automating regular tasks historically carried out by medical professionals and also providing remote access to medical advice for patients.

Remote healthcare solutions have dominated the health tech boom. A transition to solutions such as online consultations, diagnosis and treatment has been necessitated by social distancing requirements and protection of healthcare staff and patients.

Some examples of emerging health tech solutions include:

health tech report

Greater levels of openness to digital health were exemplified by the rollout across Europe of Covid-19 contact tracing apps. For many citizens, the need to slow the spread of the virus overwrote concerns they held about consenting to their movements and personal information being tracked. A clear willingness from citizens to share their personal information for the benefit of the wider population is an encouraging evolution for further innovations in the use of big data, whereby data availability and accessibility enables more precise trend analysis. Ireland’s Covid tracker app had been downloaded by more than one million people by July 2020, just five months after the first case of Covid-19 was identified on the island. Collaboration between the technology industry and the health services facilitated the use of existing technology, such as GPS mapping, to update health records, track clusters and provide treatments. Interestingly, the app also enhanced the levels of personal responsibility on citizens to update and record their own symptoms.

Credit: Markus Winkler.

Track and trace

Credit: Lukas Blazek.

As well as national rollouts, interoperability was also built into some of the apps deployed across Europe. In Ireland, both health services recognised the wider benefits of using an app which worked in both jurisdictions and in October 2020, the EU Commission and member states set up a European Federation Gateway Service which facilitated the connection of up to 20 national tracing apps. This change of mindset to enable greater openness of data has been pinpointed as an opportunity to enhance healthcare deliver of the future.

Big data For many, the term big data relates to the commercialisation potential of personal information but there is also a realisation that the increased use of technology is also creating mountains of data. The ability to mine those data mountains offers benefits beyond commercialisation, not least to better plan healthcare delivery of the future. Data analytics is far from a new concept, but the pandemic has brought about a culture change, with many of the pre-existing barriers to data accessibility and sharing now beginning to ease. It has also served to highlight the importance of quality data collection. How data is recorded and stored is of equal, if not greater importance than the amount of data gathered, with a realisation that greater access to better quality data should enhance predictive analytics.

itute.

Covid-19 has served as an example of how this could develop. Healthcare providers continue to monitor trends in patient recovery from the virus and data from technologies such as wearables are helping to form an understanding of lasting effects both nationally and internationally. Greater access to quality data is also of major benefit to those delivering health tech solutions. Tailored solutions built on real-time data will drive efficiencies and suitability of future health tech innovations and will also broaden the market, be enabling new or emerging technology providers greater access to beneficial information.

Telehealth

Credit: National Cancer Inst

At the end of 2020, the Medical Council Ireland published research which suggested a fivefold increase in the use of telemedicine since the beginning of the pandemic.

The research estimated that by October 2020 over 20 per cent of the population had used telemedicine compared to just 4 per cent in March 2020. Telemedicine is a broad-term and includes healthcare service access across a wide-range of applications ranging from telephone to Skype and Zoom. Prior to the pandemic, use of telemedicine in Ireland was largely limited to specific circumstances such as where a patient was experiencing sever mobility challenges, however, Covid-19 has largely necessitated a culture shift to a digital-first approach. At a basic level, this has meant that non-urgent interactions with the health service such as repeat prescription or minor illness are being carried out through digital means. However, telehealth provision has also involved the integration of several technologies. One example is the provision of in-home technology to allow patients who require regular monitoring and treatment to record their own information, such as their blood pressure, to inform the healthcare provider prior to a digital consultation.

The evolution of telehealth applications has also enhanced confidence in digital security among both providers and patients. However, the ransomware attack on the HSE in May 2021 will have served as an example of the challenges associated with greater levels of technology integration.

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