A Conversation on Global Implementations with Clement Ng

CN: HIMSS is a global organization and at the Chicago conference in April, there were delegations from all over the world. Their scope is a lot broader in terms of attendees and topics covered. Lots of vendors show up from around the world, in addition to payers and providers. There were country delegations from Europe, the Middle East and Asia-Pacific. We also saw a lot of content around US trends such as the interoperability showcase where demonstrations were conducted for pre-defined use cases.

DMEA, which was held in Berlin, is smaller and focused on the German, Austrian and Swiss markets. The learnings, highlights and issues discussed were typically specific to those regional markets. Also, DMEA tends to focus more on providers who are incented to improve productivity through innovation, and less focused on payers who act as administrators and are more interested in regulation and less so with innovation. This year, all angles of EMR discussions came up, since in 2022 Germany announced its KHZG (Future Hospital Act) which intends to drive digitization of German hospitals. As well, ISiK (Informationstechnische Systeme in Krankenhäusern), the federal law driving interoperability was featured prominently, as hospitals need to have ISiK-compliant FHIR^® interfaces in place by June 2023. This will impact other European countries as well.

Both events present great opportunities for Smile Digital Health (Smile). At HIMSS where our branding and market awareness is much stronger, the conversations were more focused on how we go-to-market. At DMEA, discussions centered around awareness of Smile, its capabilities and FHIR adoption. That is why at DMEA we exhibited as part of the FHIR Business Alliance (FHIRBall), an industry coalition we co-founded.

CN: Hmmm, well, countries like the Kingdom of Saudi Arabia (KSA), the Philippines, Indonesia and Egypt tend to take a wholistic approach to embracing open standards with governments as key drivers. This is however a relatively new phenomenon as national standards are still relatively nascent, as are the specifications of national implementation guides (IGs); but the ambition and commitment to open standards is absolutely there. For example, Indonesia has FHIR explicitly mentioned in its digital transformation roadmap. Egypt’s RFP for its Health Insurance Reform program specified that all data exchanges between systems to be on FHIR.  

When we engage with each country, we try to align with their digital transformation strategies and highlight ways we can accelerate their implementation with innovative use cases. We also focus on getting them to appreciate that in order to truly reap the benefits of standards, they need to embrace both persistence AND exchange of standardized data. Often, these countries are pitched by vendors who are motivated to sell their products as opposed to solutions that solve customer problems sustainably. This is where I think Smile is different from other health IT vendors. At Smile, we try to offer them advice, and solutionize what we believe to be right for them, beyond our products. We take into account the social dynamic, their goals, the people, processes, the business and economics, along with technology. One way we do this is by decoupling applications from the data tier to enable an ecosystem approach, so these countries will always control their own data and are not stuck on legacy vendors. Countries can pick and choose or even develop their own applications for their respective needs. Reducing vendor lock-in and spurring innovation are key value propositions for embracing open standards. 

CN: There is a naive impression that FHIR-based open standards will solve all health IT problems and of course that isn’t the case. But adoption of standards such as FHIR, HL7^®, CDA, CQL, SDC, BPMN, etc will go a long way towards this. Each country has a different starting point and cannot ignore legacy systems and formats (or lack thereof).  These countries are also not looking to “reinvent the wheel” and are more willing to adopt best practices from others. So, it requires that we offer the right solutions and consultation for their individual journey, as well as point to other case studies and share our lessons learnt. At the end of the day, we firmly believe that getting the right information to the right people at the right time enables automation in all aspects of healthcare, resulting in better outcomes for citizens and countries. All this can only be possible if standards are broadly adopted. Our vision is that one day, health information can be transacted seamlessly between stakeholders, resulting in what we’ve termed “the internet of health”. For countries that are just beginning their digital transformation journeys and do not have much by way of legacy systems, leveraging standards and corresponding information architectures can help them leapfrog past advanced countries like the US to achieve interoperability. 

CN: More than 96% of US providers have transitioned from paperless to electronic medical records (EMRs), which started in the 1960s. While the price of computing has reduced significantly since then, implementing EHRs, however, requires incurring significant sunk costs. This makes replacing legacy systems harder to justify, even in light of new technologies. These legacy systems have limited out-of-the-box interoperability, so building and supporting integration between systems requires significant implementation and maintenance costs. Helping developing countries or non-US markets is very different. You have to put yourself in their shoes to find different pathways to achieve interoperability.

Let’s look at Egypt, where they are ambitious in their adoption of open standards and want FHIR-based interoperable data exchanges. As I said earlier, their Health Insurance reform program has a requirement to be FHIR-based as a starting point, not as an after-thought but as a core part of their plan. However, only about 4% of Egypt’s health records are digitized today and we can’t assume that every provider there can even afford a computer. So, it is a completely different type of challenge—more economic than technical. Right now, Smile’s advice to them is to pick use cases that can derive tangible benefits in the short term such as performing structured data capture through Smile Forms, instead of relying on EHR implementations throughout the rest of Egypt to collect data which will take much longer time.  

Indonesia’s potential is awesome. They have a population of 273M people, almost all of whom are on smartphones. In August 2022, Indonesia updated its legislation on Electronic Medical Records (EMRs). They explicitly mandate all health facilities to integrate with the national health information platform by December 2023. This not only drives interoperability but also puts patients at the center of the health records. Indonesia also looks at access to health records from a national perspective, and not tied to regions or states. At Smile, we are exploring ways to automate processes and unlock value from this data-set for the country’s benefit.

The Kingdom of Saudi Arabia (KSA), though not a developing country, is an interesting new market. The Crown Prince of the KSA has laid out a strategy that maps out a common, unified view across all sectors around interoperable data by 2030. They have something called Saudi Vision 2030 that aims to provide free and quality healthcare to its citizens, among other things. They are looking to diversify their economy as much as possible and become a regional hub for various services like healthcare. Saudi Arabia could use a national data micro-services architecture in order to deliver upon their ambitions. They need a data tier that can leverage existing data stores, (like HIEs), in order to easily spin up new services for use cases such as policy simulations based on population health. To support their forward thinking and ambitions, Smile is suggesting that KSA build out a national data fabric with the persistence of data in FHIR as their data model, in addition to adopting FHIR APIs.

CN: A large part of my conversations revolve around showcasing use cases and getting global buy-in on the benefits of standardization and information sharing. We all believe that here at Smile, of course. But a large part of the industry is quite fragmented and frankly only paying lip service to interoperability. While a number of countries have begun to specify FHIR as a requirement, many vendors are selling FHIR products and telling these countries that they are FHIR compliant. The problem is that while most of these vendors offer FHIR APIs, they still rely on their on their own proprietary data models in their persistence layer. This creates an interoperability tier on the outside that looks like it is FHIR compliant, but underneath that façade, you have to do all these manipulations in order to get data to interact. And if those requirements for data exchange evolve, then the entire life cycle of integration effort has to begin again. It is just another tier of complexity that doesn’t meaningfully transform the way healthcare can be delivered.

A key message in my conversations to educate potential customers is the whole concept of adopting a Health Data Fabric (HDF) in a meaningful way. This helps bring the understanding of how it is beneficial versus one-off, point-to-point integrations that continue to lead them down the perilous path of siloization. Health Data Fabrics (HDF) include consumers and producers of data as well as storage and exchange services. A FHIR-based HDF is about both persistence and exchange. Initially, this can be tedious because all your data would live in legacy silos and you'd have to find a way to ingest them into a common store so transformation can happen. As well every implementation is different, because that’s just the reality of it. So yes, it is a heavy load upfront and there is no silver bullet, but an investment in building a HDF is an investment in your future. However, once that data is transformed into FHIR, it will always be easily consumable going forward.

That’s how these conversations start, at least.

CN: COVID proved to us that we need to find alternative models of care, beyond hospital walls and that we do not have the capacity to respond to a population health crisis. This is why everyone, and this is global, had to shake everything up and start thinking of health services differently.

France, for example, realized that they had to rethink and disrupt their traditional health delivery models. Because of COVID, they created their first digital health agency, the ANS  (Agence du Numérique en Santé). They realized that they were unable to respond to the massive shortages and inefficiencies they had with beds, healthcare workers and medication delivery.

For public health, you need information. For example, you would need to know what your drug inventory looks like because, in a pandemic, you would need to be appropriately stocked in advance. This makes sense. But, drugs also have a shelf life. So, how do we optimize that — ordering today what will be enough for tomorrow, given expiry dates and other contingencies? Well, you will need data from everywhere (clinical, social determinants, environmental, etc), constantly run models so predictions can be as accurate as possible (because nothing stays constant in an ecosystem where we have so many inter-dependencies). Such data needs to be structured and consumable for all stakeholders. This could give you information like how many people have specific diagnosed conditions currently, as well as what their clinical pathway may be in the future. Most organizations have forecasting tools with policy simulations for this. But, my question for policy makers is: ‘where does your policy simulation data come from, and is that data relevant or is it based on surveys and census data collected from prior years?’ So far, it seems that most countries do not work with current or comprehensive data, and perform simulations based on biased or limited data sets. The danger is that such static data sets may actually be misleading for policy making.

Because of COVID, health data has increasingly become a national security issue, which has accelerated digital transformation in many countries, with interoperability at the heart of this transformation.

CN: Governments and HIEs need to lead the way in building health information infrastructures — secure and flexible ones that enable the collection, capture, and sharing of information in near-real time. Now, the need for this information is largely unpredictable. It is too presumptuous to think we know of every possible health scenario and that we can plan for these permutations and combinations of scenarios in advance. Health is extremely personal yet expansive, and as such demands flexible data models that can be used in many scenarios. FHIR is that data model much like TCP/IP was for the internet. This is the concept of a health data economy where information flows freely between individuals to enterprises, to national, regional levels, which effectively becomes the Internet of Health.  Once this happens, health delivery models will be significantly disrupted and new efficiencies found — much like how brick and mortar companies were disrupted by online retailers once the internet started taking off.  Health delivery will become transactional yet collaborative in nature, driving cost reductions, improved accessibility, equity and outcomes, and innovation.

Smile’s Health Data Fabric (HDF) enables stakeholders to participate and transact on the Internet of Health, just like we do on the internet. Our HDF brings patients, providers, payers, HIEs and other organizations like research institutes together to participate in this economy. The Internet of Health should not be constrained by one technology or vendor.  We have capabilities to allow our customers to discover and transact with other FHIR APIs, regardless of vendor. Again, a key benefit of open standards. 

CN: I served in the Singapore infantry  when I was younger. So, it’s really funny, because I actually pick up on the nuances of some of George's sayings that draw from his military experience. He’d say stuff like “all the cooks grab a rifle” when we are stretched on resources and need all hands on deck to push through a high pressure challenge.  And why is that important here and now, all these years later?

When George makes these references, they remind me of my experiences and training. In a military team, you go through intense, crazy and sometimes seemingly impossible tasks together, and I learnt what it takes to “get it done”. Execution is not just a mantra but truly finding a way to give your best effort as well as motivate your colleagues to bring out their best talents and efforts to achieve difficult objectives. At Smile, I’ve had to learn that I need to earnestly consider others' perspectives in order to better motivate, drive alignment and achieve a better outcome for all.

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