Current tax revenues simply cannot afford to sustain healthcare spending levels, stated Prof. Gerard Lyons in an address to a special HISI conference held to recognise the Irish visit of the IMIA Board. Prof. Lyons argues that we must embrace a multitude of collaborative and interoperable systems and applications if we are to make progress towards a more effective, scalable and efficient healthcare system.

This special one-day HISI conference is being held to recognise the visit to Ireland of the Board of the International Medical Informatics Association (IMIA). We hope this event will provide an opportunity to learn from international experience and to gain a better understanding of the shared challenges and opportunities we face as healthcare IT specialists. In the 42 years since its foundation, IMIA has served to promote the advancement of healthcare through the application of informatics developments in clinical practice and healthcare management. It has recognised that we share many common challenges across the globe. Critically, it has fostered a mutual respect and understanding between clinicians and informatics professionals, as the only sustainable platform upon which practical improvements can be made in healthcare IT.

This conference is being held at a defining period for publicly funded healthcare systems throughout the world. Ireland Inc. represents a live and emerging case study which has parallels throughout the developed world. While the IMF has forecast a global economic contraction of about 1½% this year, most commentators now agree on a GNP decline of 8-10% in Ireland, followed by a further 3% negative growth in 2010. In Ireland, current year expenditure on publicly funded health and social services now accounts for as much as 45% of the total national tax revenue. With effective increases in taxation biting hard (by up to 20%) into take-home salaries, coupled with a doubling of real unemployment in just a year, we must all now face-up to the underlying challenge of escalating costs of public healthcare systems and question the sustainability of this form of provisioning in the medium term.

However, in the short-term, we are faced with the more immediate challenge of survival, as current tax revenue simply cannot afford to sustain healthcare spending levels. In Ireland, this comes at a very unfortunate time as the programme of healthcare transformation, led by the Health Service Executive, may well be crippled by an inability to invest in the future. Should this happen, we will all be faced with a far worse taxation burden in the future and a much poorer healthcare service.

If there is anything to be gained from the current global economic meltdown, it is the loud wake-up call to re-evaluate our current ingrained aspirations, assumptions and "ways of doing things around here". The White House Chief of Staff, Rahm Emanuel, recently advised that "one should never waste a good crisis". So, this period may well be defined by a new willingness to face-up to the stark realities of public healthcare and take a more mature and responsible attitude to promoting reform, whether as tax payers, healthcare providers, patients, carers, doctors, nurses or trade-union bodies.

Some of our most pressing responsibilities are:

• An ageing population which will drive further increases in demand for healthcare within the next 10 years – this is an unstoppable trend!
• Lifestyle choices (evidenced by increasing Body Mass Index and per capita alcohol consumption) which are already placing a huge burden on the healthcare system and this will rise exponentially unless we can tackle the problem at source – personal accountability!
• Healthcare outcomes which are poorer in Ireland for many conditions despite the high spending levels – clearly, we have an urgent need to re-think delivery processes and structures, both on the clinical practice side and on the provisioning cost dimension!
• Rising wealth which has promoted unrealistic aspirations for a uniformly high-quality healthcare, while appearing unwilling to bear increased taxation – someone's got to pay!
• A need to balance health promotion and disease prevention with the exponentially increasing costs of high-acuity treatments, as well as an evaluation of the efficacy of advanced health technologies.

While we are all conscious of these underlying challenges, to-date we appear to have been incapable of tackling them with a collective determination – perhaps it's just like we pretended the Celtic Tiger was a durable species...!

By way of contrast, the Obama administration has now begun to confront the far greater problems facing US healthcare. Evidence of their commitment to health informatics is the recent allocation of up to $19 billion in a stimulus budget for health IT spending, with a determination to achieve nation-wide implementation of electronic patient record systems by 2014. Regrettably, Ireland has been very slow to realise the potential of health IT, and we spend less than half of 1 per cent (i.e. '½'%) of the annual public healthcare budget on IT. While money alone is never going to transform Irish healthcare, a lack of spending on areas critical to healthcare transformation, will further reinforce the ineffi cient rigidities which confound our health system daily. Neither will IT on its own bring about a radical transformation of clinical and operational practice.

We need a sustained and choreographed effort that must include:

• Clinical practice change;
• Healthcare management and organisation change;
• Re-design of healthcare delivery models and operational practices; and
• Support from the tools, techniques, systems and expertise available from health IT.

But, given where we're starting from in Irish healthcare IT, we need much more than academic exhortation to achieve meaningful change in a realistic time frame of not more than 4-5 years. We desperately need to assemble a full poker hand of five trump cards:

1. Motivation: Clearly, the flames are leaping high from our 'burning platform' for healthcare transformation. The need for change really exists in absolute terms. We must now face-up to this need, honestly, and collectively – politicians, tax payers, healthcare professionals, patients and carers, and especially our very vocal representative bodies.
2. Direction: Despite the many volumes of expert opinion in virtually every care group sector, and the never-ending debate about private vs. public systems, we have not set-out a clear and viable model for end-to-end healthcare delivery in Ireland which accommodates the multitude of different needs and provisioning approaches (public, private, and voluntary). This is not a simple task and is not amenable to a political quick-fix as often advocated; nor can we simply transpose healthcare delivery models that appear to work in other jurisdictions, as these are all context-specific.
3. Powerful Friends: IT has not been held in high regard in Irish healthcare (albeit, for all the wrong reasons) but the old tapes must now be changed. We need IT based transformation to be championed at the highest administrative, political, institutional and commercial levels. We need a pragmatic consensus approach which includes: Ministers for Health and Finance; back- benchers and opposition spokespersons; Healthcare administrators – HSE, DoHC, Clinical Leaders, Healthcare IT vendors, and international key opinion leaders (such as IMIA).
4. Proven Successes: We need to demonstrate quickly that IT can really make a tangible, significant and very public difference in: clinical outcomes, better access, increased patient safety and resource efficiencies.
5. Health Informatics Professionals: Finally, we need to cultivate a cohort of health informatics professionals, cross-trained in both the technical skills of computer science and the clinical knowledge of the healthcare application domain. This may well be the most difficult challenge, as the current supply of health IT professionals is totally inadequate throughout the developed world.

Equipped with these five trump cards, we could feel confident that IT can be used to good effect both in terms of near-term crisis management and in longer-term sustainability. But if we've learned anything from the recent economic crisis it is that we are now operating well beyond the boundaries of normality and planning certainty. We cannot afford the luxury of single, large-scale all 'singing n’ dancing' IT solutions. Instead, we must embrace the reality of a multitude of collaborating systems and applications, which must become interoperable (even at a basic data exchange level) if we are to make progress towards a more effective, scalable and efficient healthcare system.

By Professor Gerard Lyons, President of HISI