Many nations have begun a serious exploration of digital health (DH)16,17 to address the pressures on their healthcare systems.1,3,9,12 Citizens and technologists are also driving related changes that facilitate growth in DH—for example, through the greater use of mobile technologies, sensors, extended reality, and artificial intelligence (AI).
These technologies are part of DH as defined by the World Health Organization (WHO),14 enabling new care paradigms that are distinguishable from older technologies like electronic medical records (EMRs). The impact of these DH technologies in healthcare in each country is captured through the concept of Digitally Enabled Healthcare Ecosystems (DEHEs).
In this article, we address three questions in several national settings in Oceania (Malaysia, Singapore, and Australia). These key questions are:
- What is the current state of progress of DH?
- What is the apparent social license for DH? (for example, given concerns about privacy).
- In the next 10 years, is DH likely to fully take hold? (for example, as evidenced by major disruption of traditional healthcare).
Here, we explore these questions based on local expert opinion in the case of Malaysia and Singapore cross-referencing with publicly available information. Let's start by considering Malaysia.
The country's early attempt in transforming healthcare was the of launching its telemedicine program in 1997.4 According to Shah Yasin, head of medicine at Monash University Malaysia, "the ... government has been talking about tele-health for more than two decades."
Another early contribution in this space was the Malaysian Health Data Warehouse (MyHDW); a key initiative commenced in 2013. MyHDW has been promoted as a sound national platform for the integration of health data (from a variety of public and private health sources) intended to improve decisions on patient care.5
In addition, nearly 20% of public hospitals in the country have implemented EMRs, but challenges to full implementation remain due to software incompatibility and inadequate ongoing support.7 As in some other countries, private hospitals in Malaysia use systems that are not necessarily compatible with those of other (including public) facilities, according to Yasin. Despite some of these strides, there remain problems with a lack of integration between systems, a lack of private healthcare involvement, and inadequate long-term investment.
In 2019, the Malaysian Director General (DG) of Health flagged a shift to a more modern DH approach, away from the historic focus on telemedicine. He stated: "We have agreed for the Tele-medicine Development Group (TDG) to be rebranded as DHM (that is, Digital Health Malaysia) ... to support development, research, and innovation of DH initiatives in Malaysia."11
In Singapore, some DH systems have been designed to move care beyond the hospital and provide valuable services to the community.
The DG further stated, "These (DH tools and interventions) are what we need to embrace digital healthcare ... to transform the current healthcare system to one of high impact, reasonable cost, with great outcomes. ... The Ministry of Health shall provide its network of hospitals and health clinics as testbeds for ... digital innovations ..."
This plan is in alignment with greater recent Internet penetration in the country, allowing wearables and mobile devices to be more widely used to track behavioral aspects of healthcare.13 While there have been some public concerns expressed about privacy in DH, in general, it does not seem to be a major concern, according to Yasin.
In Singapore, the social license for DH is quite clear, according to leading expert Adam Chee, a local representative of WHO's international DH experts.15 Chee contends that Singapore's citizens are generally savvy when it comes to digitalization and do understand the benefits of DH. This relative maturity is reflected in the actions of the Singapore government, which is transforming the country into a hotbed for research, innovation, and enterprise in smart healthcare systems. The practice is in line with the country's Healthcare 2020 Masterplan10 by which it aims to change its healthcare landscape through the mantra of "better health and better future for all." The key goals of the plan are to deliver accessibility, quality, and affordability in healthcare.
In turn, the local IT industry and health sector have driven various e-health or DH plans.a Amid the recent growth, some DH systems have been designed to move care beyond the hospital and provide valuable services to the community (for example, the Multi-Dose Medication Management (MMM) system). Some other projects have also been introduced to take the concept of "health" beyond traditional mass healthcare and redefine it as the "healthiness of people" (for example, Smart Health TeleRehab).b
Despite a recent analysis of Singapore's "e-health" by a major European collaborativec that described the nation state as the "undisputed continental leader" in the area, Chee argues that Singapore is still somewhat at the "upper-middle level" in terms of achievement. He says that "although we observe a heavy adoption of DH in various isolated areas, there still exists a need to better integrate (not just interface) the solutions at a patient (and clinical user) level. There is also a deep concern regarding data governance, security, and privacy given recent incidents in the healthcare sector."
In order to further strengthen the DH environment, Chee thinks a decade is a rather short time to effect any major structural changes, but he notes that certain aspects of traditional healthcare are being changed in Singapore, including management of health data and rehabilitation. More significantly, he expects that creative start-ups will play more of a role, for example, through utilizing cutting-edge AI.
Having considered two very different DEHEs in Malaysia and Singapore, let's now consider the situation in Australia, where there has been a long history of achievements in health IT and DH, but arguably in relative silos.6 In 2017, the Australian Digital Health Agency (ADHA) prioritized several areas in its national strategy to be achieved by 2020.2
While DH in Australia is at an exciting stage—with an ever-increasing number of healthcare providers moving onto electronic platforms in support of clinical care, and the presence of a vibrant start-up ecosystem (for example, see DoseMed and Life Whisperere)—it's still something of a "tale of two nations." For example, the general practice sector has enjoyed approximately 90% clinical computerization for many years, yet many government and privately funded hospitals still do not have EMRs.
The My Health Record (MyHR)f roll out, using an opt-out consent model, recently generated fierce debate, with various interest groups seeking to influence the choices faced by Australian citizens. Many of the concerns that were highlighted in public conversation were in the areas of data custodianship and privacy. Ultimately, about 90% of Australian citizens have not opted out having a MyHR.
This debate highlights the social licence for moving to a fully expressed DH future in Australia is not clearly established, especially when one considers MyHR is just one part of that ultimate DEHE. Such a future, with various DH systems (for example, Alive Cor by Kardiag) and DH interventions (for example, Propeller Healthh) routinely used to provide safe and efficient care would still seem some way off given they require trust in third parties around personal data custodianship in order to have widespread uptake.
We do anticipate, however, that the situation in Australia will be substantially different in 10 years due to a spirit of entrepreneurship and innovation among local experts working in DH—especially among graduates moving into healthcare. These individuals are showing an interest in DH and what it may offer them and their patients. They will, however, be constrained to some extent by the influence of the status quo in terms of poorly designed remuneration models for clinicians and other critical inhibitors.
The development of DH is distinctive in Australia, Singapore, and Malaysia due to variations in their IT infrastructure, demographics, consumer expectations, economic, and cultural settings. When extrapolated more broadly, this suggests a diversity in the evolution of DEHEs in Oceania.
While Singapore compares favorably by some measures, the Australian and Malaysian DEHEs are not as advanced as in the U.S.—the long-standing home of the Personal Connected Healthcare Alliance,i for example; or in Israel, having exported a number of DH products to the U.S.j k
In the three nations examined, challenges remain in the integration of DH systems that, if organized well, could facilitate improved wellness healthcare for all citizens. Issues of data custodianship and the maintenance of privacy have also arisen in at least two of the nations. The ultimate challenge for all three, however, is in turning promising levels of technical achievement into sustained improvements in healthcare.
DH development is distinctive in Australia, Singapore, and Malaysia due to variations in their IT infrastructure, demographics, consumer expectations, economic, and cultural settings.
1. Alami, H., Gagnon, M.P., Wootton, R., Fortin, J.P. and Zanaboni, P. Exploring factors associated with the uneven utilization of telemedicine in Norway: A mixed methods study. BMC Medical Informatics and Decision Making 17, 1 (2017), 180.
2. Australian Digital Health Agency. Australia's National Digital Health Strategy; https://conversation.digitalhealth.gov.au/sites/default/files/adha-strategy-doc-2ndaug_0_1.pdf.
4. Government of Malaysia Ministry of Health. Malaysia's Telemedicine Blueprint: Leading health care into the information age. Kuala Lumpur, 1997; http://www.moh.gov.my/moh/resources/auto%20download%20images/5ca1b20928065.pdf
5. Government of Malaysia Ministry of Health. Malaysian Health Data Warehouse (MyHDW). 2011–2013; http://www.moh.gov.my/moh/images/gallery/publications/myhdw%202011-2013.pdf.
8. Lau, F. From siloed applications to national digital health ecosystems: A strategic perspective for African countries. Improving Usability, Safety and Patient Outcomes with Health Information Technology: From Research to Practice, 2019, 404.
9. Scottish Government. Scotland's digital health and care strategy–enabling, connecting and empowering, 2018; http://bit.ly/2FfiB6j
10. Singapore Healthcare Masterplan 2020; http://bit.ly/2ZKONaW
11. Speech by Malaysia's Director General of Health; http://healthcaretoday.com.my/telemedicinedg.html
12. Swindells, M. The NHS IT Strategy. NHS England, 2017; https://www.england.nhs.uk/blog/the-nhs-it-strategy/#draft-placemat/
13. World Health Organization. Meeting on Strengthening Health Information Systems for Sustainable Development Goals and Universal Health Care Monitoring in the Western Pacific Region, Manila, Philippines (22–24 Jan. 2019).
14. World Health Organization. WHO Definition of Digital Health; http://bit.ly/36l8J6O
15. World Health Organization. WHO DH Roster of Experts; http://bit.ly/2u6gqQ2
16. World Health Organization. WHO Global Observatory for eHealth, 2016. Atlas of E-Health Country Profiles: The Use of E-Health in Support of Universal Health Coverage: Based on the Findings of the Third Global Survey on E-Health, 2015.
a. IHIS Yearbook 2016–2017; https://www.ihis.com.sg/About_IHiS/Pages/year_book.aspx
b. HealthHub; https://www.healthhub.sg/about-us
g. Kardia by Alivecor; https://www.alivecor.com/)
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