SA Health's journey to e-health

Implementing e-health services for an entire state is a daunting task, but, as South Australian Health manager for e-health services, Bill Le Blanc, has revealed, even the preparation steps are complicated tasks.

Bill Le Blanc
(Credit: Michael Lee/ZDNet Australia)

Speaking at the e-health track of CeBIT's 2012 conference, Le Blanc outlined the process through which SA Health went to transform its state-wide IT systems.

SA Health was forced to reconsider its IT systems and reporting lines because of legislative changes put in place to prepare for e-health records. Reforming the health department was a legislative requirement, relegating return on investment and other commercial considerations to be of lesser importance, according to Le Blanc. He said that the department consequently had to jump into reform headfirst.

Structural reform

Prior to the reform, South Australia's 70 state-owned hospitals all had their own IT departments, and were funded individually by health services. A significant problem was that each IT department had devised its own method of meeting the hospital's business requirements, but, invariably, departments from each hospital used different systems that were not necessarily compatible.

As part of legislative changes, SA Health moved the reporting lines from each of the individual IT departments to the SA Health chief information officer, who then had complete oversight of all 400 IT staff.

"For the very first time, our chief executive actually had direct control over every single employee in the health system," Le Blanc said.

The change of reporting lines also provided the SA Heath CIO with control over the budgets for each of the health services, which, until that point, had only seen SA Health as a source of funding, and not as a directing body.

"You've got all the different health systems spending their own budgets and making independent investment decisions. You need to be able to pull that in, and make sure that things that are being processed actually align with the strategic direction of the organisation."

He said that it also allowed SA Health to choose particular investments, and to back them with the necessary financial support. This would have been impossible, if an individual health service had tried to do it with an independent budget.

The SA Health board overseeing these investment decisions consists of health services executives, the CIO and senior finance staff from the Treasury, in order to keep it focused on the needs of the business.

Le Blanc said that at the end of the day, it was important to consider who was going to be the most affected by consolidating and reforming the state's IT services.

"If you haven't got your clinical workforce on-board, you may as well not spend any money. You can have the shiniest, most expensive, best technology in place, [but if] the clinician is not on-board, they either won't use it, or they won't use it for its full benefit."

Le Blanc said this meant that it was important for the board to not only see it as just an IT project, but to ensure that all clinicians also had a buy-in.

"The systems that we're putting in place are business led. It's chosen by the clinicians, for the clinicians. The underpinning technology wasn't even a factor in our decision-making process when we went out to market."

Workforce restructure

Between the state's healthcare facilities, there were 15 IT departments of varying sizes, which operated independently of each other and tried to do what they could for the facilities they were supporting.

"Each of them were trying to provide the full suite of services that you would expect from an ICT department, which means that almost by definition ... there was no opportunity for people to specialise," he said.

"The entire system was very fragmented and being serviced by hard-working people, but they were mostly jacks of all trades."

Le Blanc said that with the state preparing to roll out electronic heath records, that sort of workforce, as dedicated as it was, was not appropriate for the task.

"You can't run an enterprise-class electronic health records system on health-grade infrastructure with 400 generalists. By and large, the staff were dedicated and well skilled, but they were all doing things differently from each other, and there was no formal IT service-management disciplines in place."

The other half of the problem was that the existing IT workforce had bought into a self-defeating culture, where support staff would be seen as doing a good job when "putting out fires", even though the average response time for support was around the 30-minute mark.

"We had a culture that rewarded heroes and fire fighters. That kind of culture resists the implementation of structured processes that are designed to stop fires from breaking out.

"They thought that what we were doing was actually going to degrade service, because they liked putting the phone down and racing to the side of the clinician and fixing their problem, but they weren't taking a system-wide view."

Infrastructure

The problems that support staff had to solve were also exacerbated by the ageing infrastructure across many health services. Le Blanc said that the various health services had a total of 1608 PCs, which were only being replaced with the cheapest hardware available, due to limited budgets.

"We found that there were dozens of 10-year-old, Cold War-era PC-ATs around the place running DOS, because people couldn't afford to replace them," Le Blanc said.

Using the governance policy, SA Health forced these health services to rent PCs through the IT department for a maximum of four years.

"One of the benefits of that is that we now have a fleet of about 25,000 devices that are centrally managed ... and we know that [there's] no device out there that is over four years old."

SA Health also consolidated server rooms into two centralised datacentres. This simplified matters, but also brought about an increase in risk. Le Blanc said that under the old system, if a hospital's computer room failed, a single hospital would be affected. But if SA Health's datacentre is impacted, the state would lose all health services.

To combat this, SA Health put into place dual fibre links between every hospital and the two datacentres, and triple redundancy links between the datacentre facilities themselves. Network connectivity was also designed so that in the event that the link between the two datacentres is severed, a route could still be made by using one or more of the hospitals' links.

Even the dual links between the hospitals and datacentres were created using separate paths and carriers to ensure minimal impact from outages.

"They're not in the same cable trenches, and they're through different carriers, so if Optus has an outage, we still have a Telstra carrier through a different cable in a different trench," he said, adding that this redundancy guards against outages from when "one of those pesky backhoe operators comes in to fix up a cable".