Health's 'back office' crucial to modern healthcare

The Government has made much of the need to keep frontline services fully functioning, even when costs might be trimmed in the so-called ‘back office’. Nowhere would this seem more central than in health where doctors, nurses and other personnel are key to service delivery.

And yet the ability of those personnel to do their work – and their chances of raising productivity in a service-heavy system – lies in that back office. When I was elected to the Auckland DHB in 2019 it was soon evident that essential IT infrastructure was fraying and this was hampering the work of clinical staff.

At one of our earliest meetings a senior member of the management team mentioned that the country’s immunisation register was “on its last legs”. It became apparent from other IT infrastructure that practically all IT systems were beyond their use-by date and no longer supported by the original vendor. A patient administration system had been planned for years and was yet to be implemented, with much ward work still paper-based. Much staff time was spent on IT workarounds.

Within a year, the pandemic had shifted everything, with changes being made in 10 months that might otherwise have taken 10 years. Money for IT infrastructure was available; the system was in touch with patients virtually, and much care was provided via telehealth; outpatient visits were trimmed to the essential core; and staff came to regard digital, virtual, online, and remote contact with patients, and with each other, as a “new normal”.

With the passing of the peak of the pandemic the system has to a degree returned to the earlier business model, but in the meantime, digital, virtual, online and remote methods have advanced and artificial intelligence techniques are increasingly being developed and applied.

A recent report from Australia’s Productivity Commission – on which our recently disestablished equivalent was modelled – lays out the potential: use of electronic health records could reduce hospital stay; up to 30 percent of tasks could be automated by digital technology and AI; telehealth, digital therapeutics and remote monitoring could save patients hours of travel time (20 percent of consultations are now remote); virtual wards and virtual ED facilities have been trialled; some providers of advice and care have moved completely to online access (although this has to be regulated).

In the United Kingdom a research collaboration is exploring a ‘remote by default‘ model in 11 general practices and drawing lessons as to how this might or might not work for both practitioners and patients, that in the context of a wider digital telephony plan for booking, logging symptoms, and quick decisions. 

Another survey shows clinical staff are particularly keen on videoconferencing to speak to colleagues and ambient voice technology (technology that records the patient-physician conversation and converts that into clinical progress notes using generative AI). Digitising diagnostic services is also potentially a big advance.New Zealand is also making plans, particularly for primary and community care with advances in telehealth, relying more on team-based care than just the GP, and triaging and other access tools for urgent and after-hours care.    

With an ageing society, large-scale migration, technological advances and rising public expectations, expenditure on health care is bound to rise, although this depends on the political context (with percent GDP Crown health expenditure peaking in the late 2000s and declining to 2018 – a significant reduction in real terms within a decade).Yes, we need more health personnel – for example, 45 percent of family doctors are due to retire in the next 10 years – but we also need to look at their efficiency. New Zealand, unlike the United Kingdom, has no measure of health system productivity (adjusted for quality).

Many staffing ratios were established in a pre-digital era, and it is more than possible that digital, virtual, remote and online sources, together with AI advances, could reduce the amount of administration and paperwork, increase the quality and quantity of patient contact and care – and reduce the number of personnel required.

There are potential downsides we need to consider: How do we ensure continuity of care in family practice? How do we protect against a digital divide in the patient community? What online providers should we accept? Which of the online therapeutic programmes – such as in mental health –work, and under what conditions? How do we protect patient privacy and quality of contact? How do we keep ‘the human in the loop’ for AI systems? How do we reimburse fairly across online, remote, virtual, and in-person interactions? How do we ensure that when the ‘hands-on’ care takes place in, for example, surgery, the various interactions line up and contribute safely and satisfactorily to the outcome?

New Zealand has had difficulty in facing up to key infrastructure investment decisions, the most recent and most spectacularly politicised being community water services. The health system also requires investment, but not necessarily – or only – ‘bricks and mortar’. As the OECD has recently emphasised, the power of investment in remote and digital techniques in health care beckons.