I am a Swedish cardiologist who recently returned home after spending 2,5 years working in a postdoctoral fellow position at the Commonwealth Scientific and Industrial Research Organisation (CSIRO) in Brisbane, Australia. The CSIRO is the Australia’s leading publicly funded science organisation, and pays much effort, attention, and resources to the development, the clinical implementation and the evaluation of digital health solutions, with special focus on the use and effectiveness of e-Health for the management of chronic disease. This temporary position as research fellow in Australia combined with my background as a cardiologist and researcher in Sweden have provided me the opportunity (and challenge) to take stock of my experience of life and work in, literally, both sides of the world.
This piece intends to summarize some aspects of my recent e-Health research activity in Australia and provide a platform for the short exposure of my personal reflection after working in two different environments. To achieve some kind of methodological framework to my reflections, I will use the base of a recently published review paper about the hinders and drivers for the development and implementation of eHealth in daily clinical practice (1). But, beyond this framework, all the ideas here expressed are an expression of my personal and subjective opinion and should not be considered as the product of any literature review or ‘evidence-based’ material.
Why CSIRO and Australia?
First, let me express some few words about the reason why I decided to move with my family to Australia and work at the CSIRO. At the time I decided to move to Australia withmy family, I was one of the hundreds of researchers and clinicians across Europe eager to start implementing and evaluating eHealth projects at my local clinic. In my particular case, I was interested in the implementation of a mobile app for patients undergoing Cardiac Rehabilitation (CR). For that, I counted on the enthusiasm of my colleagues and patients and the acquiescence of the local clinical leadership. Soon, I realised that this was not enough. In the hope of getting more solid answers (and knowledge) on why, what and how these types of studies could be conducted, but even more important, how the studies could be adopted in real clinical practice, I started looking for international institutions that could offer me this possibility. In this search I came across the eHealth unit of the CSIRO. Through this opportunity, I joined a multidisciplinary team including high skilled people in many different fields such as IT, software development, health economics, artificial Intelligence and robotics, statistics, epidemiologist and almost all fields of knowledge that can be considered relevant to implement e-Health projects. The proximity and close collaboration of CSIRO researchers with different health organisations and clinical sites all around the country allowed us to get the best clinical partners for each project. In addition to this, geographical and populational conditions of Australia are natural drivers for the development and implementation of eHealth solutions.
Synergies and differences for the implementation of e-Health systems in both contexts
The following factors may influence the successful implementation of e-health in clinical routine practice (1):
- The individual e-health technology: I had the fortune to be in contact with some of the leading Australian health tech companies specialised in the development of e Health solutions. It is not my intention to make any attempt of comparison about the quality or the appropriateness between Australian and European health tech start-ups. My subjective impression though is that the contextual factors of Australia, including a higher degree of current integration of remote videoconsultation in daily clinical practice, and the predominant number of private clinics delivering complex health services could be a more adequate environment for the proliferation for these type of companies, and for the factual adoption of their technologies, in comparison to Swedish (or European) contexts.
- The outer setting: The inadequacy of legislation together with liability concerns may hamper the implementation of e-health systems at an organisational and health professional level (Ref). In this regard, the creation of common standards and legislation may help to reduce health professionals’ and organisations concerns over patient data safety and professional liability. The recent implementation of the General Data Protection Regulation (EU) 2016/679 (GDPR) law on data protection and privacy for all individual citizens of the European Union (EU) is, as my understanding, a step in the right direction to unify legislation in this field. A complaint that I have heard from my Australian colleagues is concerning the hinder of having different regulations and legislation in different states of the country. Obviously, these types of uncertainties is not good and could be avoided with the implementation of common legislation, as what GDPR represents in Europe. Incentives by government organisations and other external stakeholders may facilitate the adoption of e-Health by healthcare organisations. In this regard, I have not found essential differences in the way that eHealth researchers from Europe and Australia look after and obtain their financial sponsorship. Reimbursements for adoption and pay-for-performance initiatives can also be considered as a “hot issue” in Australia, considering that many of the private practitioners and private health organisations receive direct payment from the users. Of course, this discussion is also very relevant in Sweden and Europe, but my subjective perspective is that this is not discussed with the same intensity (passion) as in Australia.
- The Inner settings: A frequent reason for unsuccessful implementation is that the information systems do not fit well with work practices or daily clinical work. This is a common scenario everywhere. Still, I have perceived an increasing attention in my Australian colleagues for the utilisation of person-centred (also denominated design-thinking) strategies to develop e-Health in cooperation with the users (patients and staff) which potentially could improve the grade of involvement and utilisation of e-Health systems by health care providers. For sure, there are also similar initiatives in Scandinavia and other parts of Europe so, again, it is not the objective of this text to establish any sort of comparison in this particular issue. Leadership engagement and management support at all stages of the development are also important factors for success of implementation processes. There are many examples of how inconsistent and unengaged leadership has damaged or delayed good projects.
- Structural settings: A practical personal experience that can show the importance that structural settings may have for the successful implementation of e-Health. In the last years, I spent a significant amount of my time working in the CR services of a hospital located in northern Sweden. In Sweden, CR outpatient services are usually integrated in the cardiology department of secondary or tertiary high specialised hospital. Australia has, in general, a different approach as the CR centres operate as independent units from the hospital, which are principally managed by nurses and allied health staff (often physiotherapists), and where cardiologists are only involved if specialist intervention or medical treatment advice is required by the staff working at the CR centres. In my opinion, Australian nurses and allied health professionals are more open to the adoption of e-Health in daily work at their sites, compared to their Swedish colleagues. At the end of the day, what e-Health technology brings is improvements in communication, not only with their patients but also with interdisciplinary communication. In Sweden, for example, this communication between the nurse and the specialist doctor is more or less taken for granted as they usually work in the same team, or, at least, “under the same roof”. In this case e-Health is not perceived with the same intensity as a useful interdisciplinary communication tool, with the capacity to facilitate their daily work. This positive perception may represent a strong driver for the adoption of e-Health by health care providers in Australia. The availability of suitable infrastructure features including electricity supply, access to reliable internet connectivity, access to computers and access to phone lines and mobile phones are essential for implementation success. These features, more or less granted in our old Europe, are not always secured in vast areas of Australia, in particular where the most vulnerable population lives (for those by definition who potentially could benefit most from eHealth implementation).
- Educational opportunities to Individual health professionals: Time availability to learn and training opportunities to staff in the use of new e-Health systems aimed to provide a period of transition in which end users can become familiar with and learn how to use new e-Health systems is important for a fruitful implementation. I have not come across neither in Australia nor in Sweden specifically allocated initiatives to allow health professionals to learn new e-Health procedures and systems, especially when the implementation of this systems requires a change in the “model of care” which is complex and time-consuming. What I have found in Australia is the existence of particular educational initiatives at university level towards the integration of eHealth in the curriculum of medical students. This can be considered as a first stage for allowing future practitioners to “practice” e-Health during their educational process and hopefully in their future clinical work. These educational initiatives help to create interest and positive attitudes for the adoption of e-health systems in future generations of health professionals.
I would like to finish this writing highlighting that the meaning of this text is not to compare the “idoneity or suitability” of respective health care systems or organisations for e-Health implementation in Europe and Australia. In fact, we should not consider the option to compete between us for the honour to be the first one achieving the successful integration and adoption of eHealth technologies in clinical practice. Rather, I would say that international collaboration is a key factor to achieve this integration. In this regard, I would like to mention the example of the Diversity-1 study (2), an initiative to validate an evidence-based Australian CR mobile platform in five different European public CR centres. Research initiatives like this could be seen as a seed for the creation of an effective collaborative e-Health implementation among clinical sites of the European Union (EU). The implementation of common pan-European eHealth programmes might do its bit to “build” a people-centred agenda towards an effective political construction of the EU.