Rethinking Healthcare Delivery in the Age of COVID-19, Digital Transformation

Herko Coomans is a digital health policy coordinator who builds international alliances and partnerships at the Netherlands Ministry of Health, Welfare, and Sport in The Hague.

Between 2013 and 2017, he co-created and enabled the National Health Information Council, the “whole system in the room” public-private governance council setting the course for patient access, interoperability, and health information exchange in The Netherlands. He has 15 years of experience with e-government development but has found his heart is in digital health and innovation.

In this interview with the Journal of AHIMA, Coomans discusses primary healthcare initiatives for the Netherlands, the COVID-19 response, and how disruption will shape the future of healthcare.

This interview was lightly edited for length and clarity.

AHIMA: What are the Netherlands major areas of focus in healthcare?

Coomans: As everywhere, the COVID-19 pandemic is the top priority in the Netherlands and across Europe.

In the Netherlands, government does not deliver healthcare services. All healthcare providers are private entities and not-for-profit organizations. To keep healthcare affordable and accessible we need to shift to a healthcare learning and adaptive system that allows for both globally aligned missions and meaningful regional and local implementations.

At the core of this shift is the ability to provide the right care at the right place. The essence of this philosophy is moving point-of-care delivery closer to people’s homes and replacing care delivery with other forms, such as [virtual services].

That means:

• From sickness to health—working from the way people function in their environments as the starting point, paying attention to health, behavior, prevention and detecting illnesses early
• Digitization—from off-line to everywhere, accessible support and care for everybody
• Doing things smarter and differently—suitable and effective care that fits in with learning experiences and the context
• From primary, secondary, and tertiary to cohesive care—with good outcomes in terms of the perceived quality of life
• From rising costs to long-term affordability—at an affordable social cost

AHIMA: To implement those kinds of initiatives, how do health information professionals need to think about data?

Coomans: Data is going to play an increasingly important role in care. Citizens have the right to a digital copy of their health data. That makes it easier to organize cohesiveness in the care sector because all the information then converges on the patient.

This places demands on the healthcare provider, and therefore on the training courses. Healthcare providers will have to be capable of dealing with well-informed, vocal patients and they will have to overcome their unwillingness to go in at the deep end with new technology. It also demands involvement from enterprising parties outside the care sector who have already acquired more experience in this area and are able to apply it in the care sector.

• E-health promotes self-management, shared decision making, cooperation, and care networking
• Information at the right place at the right time is an integral part of good care
• Give people their own data in their own personal healthcare environments (PHE)
• Build a quality framework for exchanging data electronically
• Encourage evaluation of the effectiveness and efficacy of new innovations
• Further strengthen the digital skills of professionals and people in general
• The governmental authorities provide clarity about the use of personal data and privacy

AHIMA: Are there any key initiatives you wish to highlight?

Coomans: More people want to better understand their health status. MedMij, an initiative of the Netherlands Patients Federation, was founded in 2015 by the National Health Information Council as a public-private collaboration between participants in the care sector, payers and the Ministry of Health, Welfare and Sport.

MedMij ensures that anyone who so wishes has access to their health data in a personal health environment of their choice. This could be an app or a website, for example. To do this, such an app or site must be able to communicate securely with all the locations where the information is stored. These could be the healthcare information system of a hospital, the physician, the clinic or the pharmacy.

AHIMA: How do healthcare stakeholders participate in MedMij?

Coomans: MedMij is the standard in the Netherlands for the secure exchange of health data between care users and care providers.

Anyone that is certified to meet MedMij’s criteria may use the MedMij label. The MedMij label stands for the secure and reliable exchange of health data within MedMij’s stringent parameters. This label is available for apps, websites or personal health environments (PHE) that demonstrably meet MedMij’s criteria. The label is also visible to healthcare providers or other healthcare professionals who exchange details through MedMij.

MedMij’s core task is to facilitate the digital exchange of health data between residents of the Netherlands and their caregivers. MedMij is also creating confidence that this is done in a secure, affordable, future-proof, and user friendly way.

One of the ways MedMij is doing this is by designing a solid framework. The agreements contained in the framework are essential to create the trusted environment in which patients and caregivers feel secure to exchange health data and thus get the system off the ground. This trust is symbolized by the MedMij label that indicates that a product or service is compliant with the MedMij Framework. You could see MedMij as TEFCA for personal health data outside the healthcare system.

AHIMA: Who are the Framework’s participants?

Coomans: The participants in the Framework are service providers. We distinguish between two types of service providers: service providers in the individual domain and service providers in the care providers domain.

When compiling and filling in their personal health environment, care users add a service provider in the individual domain. For example, the supplier of an app or website with the MedMij label.

Caregivers work with service providers in the care provider’s domain. They are the suppliers of IT systems in a healthcare institution. Service providers that participate in the Framework and the caregivers with whom they have contracts are identifiable by the MedMij label.

Depending on the agreements made in the Framework, the MedMij network links the individual’s and the caregiver’s domain.

Because care providers make agreements with IT providers, the Framework remains manageable. After all, it is not necessary for care providers and personal health environments to make all kinds of mutual agreements. Only the IT providers in the individual and care provider’s domain need to meet the MedMij Framework criteria to ensure that health data can be exchanged between care users and caregivers.

AHIMA: What has been the impact of COVID-19 in the Netherlands?

Coomans: Where to start answering this question? We haven’t seen the tail end of this pandemic yet and there’ll be many evaluations, with valuable lessons and proposals for change.

All I can give is my personal view, but I can say that this crisis exacerbates what was already broken in our healthcare system. Where there were problems with accessibility, they’ve increased because regular healthcare operations have been scaled down. People are postponing necessary care procedures, either because they fear going into hospital or because those services have been suspended or delayed.

This has a huge impact in health and is doing a lot of damage. Because of the big focus on COVID-19 health issues, these people do not feel seen. This adds to the already eroding trust in healthcare institutions and authority. Mistrust was always there, but the crisis also exacerbates the lack of trust in science at levels previously unseen (at least by me).

The crisis shows where we’ve grown complacent because things seemed to work as intended, but now turn out to be built on air. Relationships we thought were good turn out to be ineffective. And that probably is vice versa as well: we’ve had to shift gears and focus rapidly, sometimes with little attention to the negative effects.

On the other hand, this crisis has also shown the truly amazing flexibility of the human ingenuity and drive that has gotten us past the first wave of this crisis. Everywhere the system was broken, unprepared or absent, we have seen people jumping in from unexpected backgrounds and use creative solutions to drive us forward.

So many companies offered to help out in surprising ways, just to be able to be a positive force for change. There’s been a huge push for transparency, with source codes of exposure notification apps being developed out in the open, with full use of all the constructive criticism provided by the general public and experts alike. The sense of responsibility with which frontline healthcare workers from all over the place joined in providing critical care under difficult circumstances was and still is awe inspiring, and again shows the value of human drive and inventiveness.

It's too soon to draw conclusions, but I’ve seen the extremes at both ends of the hope-despair spectrum.

AHIMA: What does the future hold?

Coomans: Uncertainty. Disruption. Change. And not all voluntary or for the better. But we now have the opportunity to change some of the patterns we have been stuck in for too long and use the lessons we are learning and have learned the past decades to make some changes. Basically, the future is a huge experiment.

Matt Schlossberg (matt.schlossberg@ahima.org) is editor of the Journal of AHIMA