Part 8: Ernst & Young's report: Assessment of implementation of the HealthTap Solution

8.1
After the contract was signed between Waikato DHB and HealthTap, staff in both organisations worked hard during the 60-day implementation period and subsequently to implement the HealthTap platform.

8.2
Eventually, through an iterative process, Waikato DHB reached the point where it considered that it had obtained a minimum viable product. That is the position where enough of the core features of the HealthTap platform had been implemented to enable them to be used and to support feedback for future development.

8.3
As we noted in Part 1, the terms of reference for our inquiry considered looking at Waikato DHB's management of its contract with HealthTap. That would have included looking at aspects of how Waikato DHB implemented the HealthTap platform. However, in February 2018, after our inquiry was already under way, Waikato DHB decided to commission its own investigation into the SmartHealth service that it was providing through the HealthTap platform.

8.4
It engaged the professional services firm EY to provide an independent assessment of the "functionality, implementation, costs and benefits of the technology platform HealthTap, in the context of its SmartHealth initiative". Waikato DHB had contemplated a review at the end of the two-year contract period and that is the work EY was commissioned to perform. Waikato DHB made EY's report public in May 2018.

8.5
We decided that, given that public resources had been used to review the implementation of the HealthTap platform and to identify options and recommendations about virtual care, it would have not been sensible for our work to also cover implementation. Therefore, we decided to focus our inquiry on the sourcing phase of the procurement process, rather than on the implementation and management of the contract after it had been signed.

8.6
For the sake of completeness, in this Part, we summarise some aspects of EY's report that we consider relevant to our inquiry.

Summary of aspects of Ernst & Young's report

8.7
Virtual care represented an important strategic direction for health organisations in the Waikato and New Zealand.

8.8
Where the service offered through the HealthTap platform met a particular clinical need, it performed well.

8.9
Waikato DHB's decision-making about the HealthTap platform's implementation was influenced to a considerable extent by the pricing arrangement in the HealthTap contract.

8.10
Pricing was through a fixed annual licensing fee rather than progressive increases in consumer and clinician registrations or use. This meant that Waikato DHB was under immediate pressure to achieve volume through a "big bang" approach, rather than a progressive and staged roll-out with interim evaluation phases.

8.11
The change management team in Waikato DHB became involved in the HealthTap platform implementation in November 2015, only after the contract was signed. Programme reports produced by the change team told of a multitude of issues with the technology and the unwillingness of Waikato DHB clinical staff to change their model of care.

8.12
As doctors and consumers reported to EY, a prime trigger for patients to register for the SmartHealth service was their doctors' promotion of it. However, doctor advocacy for the SmartHealth service was not strong because of the HealthTap platform's reputation inside Waikato DHB and an unclear implementation plan. A particular cause of its poor reputation was HealthTap's design for the United States' healthcare market, which meant that it had attributes that were at odds with Waikato DHB's clinical culture and ways of working.

8.13
A considerable period was spent reorienting the HealthTap platform to better fit the Waikato DHB operating environment. However, by this time many clinicians had formed negative views of it. Users also experienced major issues with data and connection availability in rural areas. This was not tool related but added to the negative perception of the HealthTap platform.

8.14
HealthTap's operating model did not fit well with the New Zealand healthcare context, and the application had usability issues in the Waikato DHB operating environment. This meant that:

• the "off-the-shelf" HealthTap platform was very United States-focused when it went live in the Waikato, which alienated local clinicians and consumers seeking to use it; and
• considerable unanticipated time and expense was put into tailoring the platform to Waikato's outpatient model and IT requirements, and tailoring the content and functions for New Zealand users.

8.15
EY's work identified the main capabilities that the HealthTap platform had. EY also identified the capabilities that it expected to see in a virtual care application but that were not available in Waikato DHB's implementation of the HealthTap platform.

8.16
The implementation of the HealthTap platform lacked a clear direction, transparency, or open communication, which was a significant barrier for organisational and sector support of it:

• There was an absence of clear and unified leadership direction and communication, combined with a similar absence of pre-defined functional requirements developed through stakeholder engagement and of an explicit implementation plan.
• Together, these factors meant that there was no organisational alignment on the desired model of care that would support virtual consultations, which in turn damaged the credibility of the HealthTap platform with Waikato DHB staff.
• Medical stakeholders, in particular, reported feeling alienated from a technology platform that was imposed on them without consultation.

8.17
The way the HealthTap platform was introduced undermined existing service and technology initiatives, preventing a collaborative inter-organisational approach:

• Other health organisations in the Waikato and wider Midland region were surprised by Waikato DHB's introduction of the HealthTap platform. Organisational relationships suffered as a result.
• Primary care providers felt that the introduction of a DHB-funded after-hours primary care service using the HealthTap platform was a unilateral action at odds with the existing after-hours service agreed with, and funded by, Waikato DHB and that a better outcome could have been achieved through collaboration.
• The largest primary care network in the Waikato region also had work under way on a practice management system with some virtual care capability. It reported feeling "blind-sided" by Waikato DHB's adoption of the HealthTap platform.
• Waikato DHB stakeholders interviewed and surveyed by EY unanimously acknowledged that Waikato DHB as an organisation was not ready for the change. There was no recognition of a "burning platform" for virtual care and a strong sense that the HealthTap platform was being imposed on a sector that did not recognise the need for it.

8.18
Using reports on Māori engagement together with EY's interviews, EY identified that there were some barriers to the uptake of HealthTap by Māori stakeholders. Despite those barriers, Māori stakeholders were generally clear that there was a place for virtual care solutions in their communities.

8.19
Consumers interviewed by EY viewed HealthTap as a good option to counteract some of the perceived access issues with Waikato's health services and was a positive step towards the future. Consumers also used HealthTap as a medical reference library containing credible information. Consumers also identified areas where HealthTap could not replace face-to-face service delivery or could be improved to better suit the consumer's needs.

8.20
Although a governance structure was set up for implementing the HealthTap platform, this was reported by stakeholders to be only loosely used in practice:

• It was intended that there would be a whole-of-system governance body established to ensure that virtual care was integrated with the wider Waikato health system. However, this leadership group did not eventuate, meaning that the only point of project governance lay with Waikato DHB's Board.
• Although a Virtual Health Service Change Steering Committee was established, it "did not have overall ownership of the programme".

Uptake and usage of the services

8.21
EY assessed the uptake and usage of the HealthTap platform. It found:

• a total of 10,031 unique patient profiles were registered from 1 December 2015 to 6 March 2018 (2.3% of the Waikato resident population);
• most patients (87%) activated HealthTap after registering for it;
• 3125 unique clinicians registered with HealthTap during the study period;
• 50% of clinicians activated their HealthTap account after registering for it; and
• 80% of clinicians did not complete the online training tool.

8.22
EY determined that the overall numbers of consumers using the HealthTap platform was lower than the aspirations in Waikato DHB's strategic business case. However, in the context of a two-year trial testing a new way for consumers to interact with health services, EY considered the uptake to be encouraging and a recognition of the potential for virtual care to be a viable mode of service delivery.

The costs

8.23
EY also assessed the costs of the HealthTap platform as a service and its implementation. It was difficult for EY to confirm that Waikato DHB's spending records were complete. EY concluded that the amount Waikato DHB paid HealthTap for the use of the HealthTap platform was about $15.4 million. In comparison, EY concluded that the strategic business case request was for $14.8 million for that purpose.

8.24
Waikato DHB incurred other costs in delivering its SmartHealth service. EY concluded that, in total, Waikato DHB spent about $26 million on the SmartHealth service, including the costs of the HealthTap platform. The other costs included the costs of devices and staff time.