Charles Alessi: Think of the Future as One Where the Best of Every System Has Survived and Thrived

Digitilisation in healthcare has already achieved quite a lot. Shift from paper to digital formats has been completed in many if not most cases, hospitals use hundreds of apps on interconnected devices, they rely on digital infrastructure and interoperability standards to exchange health data. What further steps in healthcare digitalisation may be taken in the future? CIFS talked to Dr Charles Alessi, the Chief Clinical Officer at HIMSS, Healthcare Information and Management Systems Society. Dr Alessi has a vast experience in digitizing healthcare systems, he advises governments and international institutions on further developments in this field.

Q1: Part of your responsibilities as HIMSS Chief Clinical Officer is relationship-building among international clinician-focused communities within and outside HIMSS. Professional online communities of healthcare personnel have gained prominence as healthcare stakeholders in the recent years. How do you see the future role of such online communities of doctors and nurses, what is it they will do what they do not do enough now?

The digital transformation of health and care has accelerated dramatically as a result of the pandemic. This has accentuated the importance of data and the use of data – both in the realm of pandemic preparedness, particularly health security, and also in the management of non-communicable diseases where we have significant waiting lists to manage. These are both global issues. HIMSS is a mission driven member organisation and is to reform the global health ecosystem through the power of data and technology, and as data has now become everybodies business in that it affects every person who works in the health and care space – doctors and nurses as well as information and data specialists are now a core audience. My aspiration is for HIMSS to continue to develop suitable content and continue to support this core audience.

Q2: You have been also advising extensively on digital health interventions that involve behavioral change. Can you describe the recent dynamics in this field and elaborate on the near and perhaps, not so near future in this field?

The key dimensions to better manage non communicable diseases for any health system are multiple. Organisations have to have well developed and personalised clinical governance structures to ensure care is consistent and evidence based and most organisations are working hard to achieve this. Outcomes will improve immeasurably if the populations served are also activated as they will then take a more active role in managing their health and reducing risky behaviours. Health workers have a significant role to play in the process of behaviour change not only in actively assisting this, and the concern here is the woeful training they are receiving in achieving this, but also in encouraging this behaviour change through extrinsic motivational approaches. The use of incentives, properly and carefully contextualised within the health and care system they are deployed in, has been shown to accelerate better outcomes and lead to the intrinsic motivational change that is at the heart of ensuring people take more responsibility for their own welfare.

Q3: You are the senior advisor to Public Health England on aging, also you are involved with WHO in the same area. Though it is hard if possible at all to generalize on any global trends to aging, what new global developments we may expect here? How do social determinants to health may aid a shift to a productive, healthy aging?

The world is changing very fast as a result of this pandemic. Attitudes are also changing and some of the trends we were all trying to encourage, like ensuring we forgot about the stereotypes associated with older people were also helped by a few factors, like the workforce shortage, which aided older people who wished to continue working, as well as the drive to personalisation, which made the choices people made around their lifestyles more likely to be heard irrespective of their ages. Age has now ceased to be the determining metric that determines whether you work or you do not, or whether you are a productive person who has meaning and purpose or someone who passively sits at home wondering how to fill their day.

Q4: You have advised quite a few major corporations and national governments on systemic healthcare reforms and digital interventions in healthcare. How do the two depend on each other? What policy shifts do you consider to be pre-conditions to successful deployment of innovations in healthcare?

Digital transformation and health reform are intertwined and in essence both have the capacity to lead to a renewed health and care system. For a start, digital transformation and telehealth are not merely a translocation of existing ways of working to the digital space, but an opportunity to fundamentally rethink and redesign the workflows of care putting much more emphasis on personalisation, person focused outcomes and more holistic care. The financial metrics that drive health and care systems inevitably need to follow and this is all part of the movement as we move from volume to value. The most fundamental and most difficult shift is achieving this. Systems need to evolve iteratively so prevention and risk reduction of populations becomes part of the key performance indicators that drives payment.

Q5: What are the main lessons to learn when digitizing healthcare systems, in your experience?

One should never underestimate the importance of buy in and engagement. One of the most critical factor that can either delay or accelerate digital transformation is the readiness of the workforce to work with the pace of change, and the inevitable changes to workflows that the process brings. Digital transformation is less about wires and boxes and more about people and getting buy in to change. Therefore, for me the main lesson is that investing time in getting clinicians to both understand and be part of the changes is one of the key determinants of success and every hour spent doing this will pay back dividends sometimes even greater than getting the highest specification possible in hardware and software. Digital transformation is not only about the technical aspects of delivery of care, it is also about people.

Q6: Most changes in healthcare systems occur under the hood, they are not visible to patients. What future developments in the healthcare sector may be visible to us all, especially in primary care?

Patients and citizens have an overriding expectation of a health system. This is for it to work in terms of outcome, to work seamlessly, and to work in a way which reflects their needs and aspirations. The new world we are looking at, will have access and transparency at its core. The efficient and seamless operation of patient access portals is one of the ways that people will engage in healthcare and that changes are taking place. Thus one could expect to see patients becoming more engaged and activated as a result. One could also expect that the debate around the use of data – in many respects the “life blood” driving health systems, to heighten. Primary care will continue in its role as the most utilized portal to access care and the aspiration is that increased interoperability will increase transparency both for primary care staff as well as for people using the system.

Q7: How much decentralization do you expect in future healthcare? I mean not only decentralized approaches to technologies to be employed (DLT etc), but also in the decision-making process in healthcare?

There is a potential dilemma to be addressed between decentralisation and consistency of delivery of care. This is because decentralisation has incorrectly been equated with the ability to promote “walled gardens of governance”. This is by no means inherent in decentralisation. We know that the most efficient and effective health systems are those which are closest to the populations they serve. Thus at one level, smaller is better. But smaller does not imply the absence of governance between these smaller units as there are many situations where a more national aggregated approach is what is required. It is also clear that the closer decision making is to the patient, the more likely that the patient will feel engaged and involved. My sense is that it is possible to walk the line between these approaches and this is what everyone should be aiming for, although that line will vary depending on the geopolitics of the health and care system.

Q8: How do you envisage an ideal decision-making process in healthcare, from developing policy to implementing a concrete action plan? What do you see as major obstacles on the way to make this vision a reality?

It is relatively easy to develop a theoretical system of decision making which is sensitive to local need but also cognizant of national or enterprise level. However what is key here is the behaviour of people who are in decision making positions. In some health systems, decision making is devolved to the localities but financial control is retained centrally. It is no surprise that this asynchronous way of working encourages aberrant behaviours. Devolvement to local levels needs to be all encompassing. However, one also needs to be able to aggregate localities where necessary, and also for localities to be cognizant of the requirement to work collegiately for the greater good. Thus, clear governance and transparency should be at the heart of each system.

Q9: Last, to reverse the future talk, what of modern healthcare, in your opinion, will stay with us in the future?

I would suggest we need to think of the future as one where the best of every system has survived and thrived. This is not about a binary approach where digital approaches (for example telehealth) will take over and ‘old fashioned” analogue (face to face) interactions will cease, but more about a blended approach. Face to face interactions will need to continue in certain situations and in a world where longitudinal relationships will thrive. Compassion and care is not as easy to deliver using two dimensional telehealth. Human to human interaction will remain at the heart of delivery of healthcare and we must aspire to blended approaches where we exploit each modality to its maximal extent.