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HTN Now: the opportunities and challenges for national digital health strategies in small island states

At HTN Now we were joined by a team of researchers to discuss their work exploring the opportunities and challenges for national digital health strategies in small island states, looking specifically at Bermuda.

We welcomed Dr Kathrin Cresswell and Jay Evans from University of Edinburgh; Dr Rosemary Foster from the University of Cape Town; and Laura Evans and Alan White of Interactive Health Limited.

Alan began by providing some context. “Bermuda is very unique. It’s a very small island with a population of just over 60,000 – that’s smaller than Inverness in Scotland. It’s a very wealthy country, at least superficially, spending 11 percent of its GDP on health. In terms of ethnicity, it’s almost split in two, with a population that is roughly 50 percent black and 50 percent white. Broadly speaking, these two groups are to an extent divided, which has an impact on health.”

These characteristics, Alan noted, presented an opportunity for the research team to regard Bermuda as “a living lab”.

Jay picked up on Alan’s point, providing more background information on Bermuda. “Like many small island nations, it is very complex in terms of its healthcare system,” he said. “It brings all of the complexity of a large state in many ways, and there are several actors that play a part in providing health services. The Ministry of Health is responsible for the overall health system on the island, but there’s also the Bermuda Health Council; they are responsible for health regulation. Then there is Bermuda Hospital’s Board, which essentially runs the largest hospital on the island, the Kind Edward Memorial Hospital with about 200 beds. It also runs two other facilities, a mental health and wellness institute, and an urgent care centre.”

The way that healthcare is delivered, and the focus on insurance, is similar to the United States in some ways, Jay explained. “There are two government sponsored health plans in Bermuda, and there are also private insurance providers who provide coverage for the majority of the population. But they certainly don’t cover everyone – there are still large swathes of the population that are left uncovered or under-covered.”

Bermuda: methodology

Jay handed over to Kathrin, who led discussion on the methodology used in their Bermuda research.

“We did mainly qualitative work, which is quite unusual for digital maturity assessments. We had a very short amount of time to spend on the island, and during this time, we spoke to about 42 people from a range of demographics. We also distributed a questionnaire to do some basic quantitative analysis.”

“Just as a caution, this is qualitative work, so it’s based on our interpretations,” Kathrin pointed out, “and not necessarily what everybody would agree on. The other caveat is that we spoke mostly to people who were already engaged, and that will become important as I take you through the narrative, because they had a massive problem with engagement.”

Starting with the positives, Kathrin noted that they found a positive overall climate for change, with strong local drivers for digitalisation of health and care. Due to Bermuda’s small size, there was also a perceived advantage and an opportunity to build personal relationships and share informal knowledge. The team found that respondents mostly saw digitalisation as an opportunity to rationalise the number of existing IT systems and tackle interoperability. At the time of the assessment, there was also strong governmental support for the digitalisation of health and care.

With regards to the general technology infrastructure of Bermuda, Kathrin noted health IT infrastructure was limited. “Bermuda has a very limited adoption of digital systems compared to other high income countries,” she said. “They have national databases that exist for certain diseases, such as a national tumour registry, a cancer registry, and so on – but they’re not coordinated at all. Most of the systems are old, and still fed by paper, and not all were mandated.”

There was some national integration based on insurance data, and at the time of the study, there was a programme of work establishing unique patient identifiers. The team also noted that Bermuda had “some type of integration through the COVID-19 infrastructure”, for example around immunisation records; but this did not integrate with other systems, and it was decommissioned later in the year.

“There were strategic challenges, associated with changing governments and leadership,” Kathrin said. “There were several previous historic attempts at healthcare reform, but they were unsuccessful, and they didn’t achieve their planned objectives. That led to an inability to plan digitalisation initiatives in the long term. Then there is risk of loss of organisational memory in relation to learning and actually building on those previous initiatives.”


Next, Kathrin came back to the challenge of engagement. “We found a lack of engagement – actually, there was some explicit opposition to previous initiatives of some key powerful stakeholders, mainly including primary care physicians. They were vocal, and they did a massive social media campaign against it, actually ending up interrupting policymaking.”

The team also found potential conflict of interest and fear of competition through visibility of cost, due to how the system was set up. “That was especially amongst GPs and pharmacists, because they were essentially small private businesses,” Kathrin noted. “There were a range of complex stakeholder relationships, and a mix of public, private and independent health and care entities – you could go to a lab and get a blood test done, no problem, but they were not aligned, and in some instances were in direct competition with each other. Further, there were historic tensions, for example between hospitals, between the hospital and the community, or between GPs in primary care. That might also have contributed to the fragmented relationships and lack of communication going forwards.”

Kathrin revealed that they found that primary care physicians felt that they were removed from the hospital; and because the hospital was the focus in digitalisation, these physicians were worried that they would just have electronic health records suddenly imposed on them. Her team focused on the private sector, with Kathrin noting that the healthcare services here were seen as the “the difficult ones” that had to be on board for digitalisation to work. This was due to the fact that the hospital, with its own governmental budget, had already implemented an electronic health record.

However, overall, Kathrin said that “people were pretty enthusiastic about digitalisation. The majority of interviewees looked at it as an opportunity to integrate care, reduce waste and duplication, and increase safety and quality most importantly. Physicians mentioned pain points and adverse patient outcomes due to a current lack of digital integration, and said they were feeling ‘blind’ to what was happening to their patients in the hospital or in overseas hospitals. They expressed their frustration that they could not feed potentially important information into hospital systems, and we were given examples of people dying because of this.”

The hospital system as a first step toward digitalisation

Kathrin said: “The hospital implementing Cerner was seen as a first important step towards digitalisation. They did this six weeks before we came to the island. At the time of data collection, the system was still embedding and they had deployed relatively limited functionality, so they couldn’t do secondary uses of data yet. People were still getting used to new ways of working; there was limited integration with community systems, and the community had read-only access. We also observed a perceived lack of transparency in the community around who had access to Cerner and in what capacity, so that complicated relationships.”

Kathrin specified that some community settings had access to Cerner and were already seeing the benefits, whilst some didn’t. Reasons for non-use included that Cerner was seen to create paper reports for physicians with information that was not perceived as relevant, and that additional work was needed to log in and out of multiple systems. In addition, Cerner was not accessible to private labs and insurers.

At the time of data collection, she noted, there was still some manual integration of information across systems which meant that “data transfer between settings was often inaccurate, raising concerns about patient safety.”

With regards to perceived risks and barriers to adoption reported by physicians, the team found that physicians did not want to feel monitored; that they noted potential risks to confidentiality due to Bermuda’s small size; and they did not want others to be able to see potentially commercially-sensitive information.  Some worried that reimbursement structures would change and they would be paid less. In addition, Kathrin said, “They felt they couldn’t trust the government in decision-making, and decisions were perceived to be driven by the need to save money.”

Considering these outcomes, Kathrin found that there were “no incentives for physicians to buy systems that would integrate or interface with Cerner”, “no incentives to record data digitally”, and “no incentive to actually input and engage with the digital strategy”.

Digital health governance maturity in Bermuda’s healthcare ecosystem

Kathrin moved on to talk about the current level of digital health governance maturity in Bermuda’s healthcare ecosystem.

“We found that there was a perceived lack of oversight and regulation. You would think it would be relatively easy in a small country, but investment in health was not regulated or mandated nationally. Existing legislation was seen as outdated, and there were no clinical standards of practice or care.”

As many people trained overseas and then came to Bermuda, they brought their own training and codes of conduct, Kathrin added. “It was complicated, and coding was not applied consistently. There were also no incentives to code, and different structures were used across settings.”

The team found that people perceived the government to be not as strong as it should be in developing policy and in operationalising legislation. “There was a perceived lack of specialised digitalisation knowledge, and a challenge with retaining staff which meant that people would leave and take their knowledge with them. Leadership was seen as important, but at the time of our data collection, this leadership was spread too thinly and there was very little control and monitoring of things like conflicts of interest.”

Billing and health equity

“As the system was insurance-based, there’s a huge risk to human-centricity of systems for both healthcare staff and patients,” Kathrin highlighted, “because systems are designed for billing and that limits their day-to-day usability. Billing was seen as extra work by healthcare staff, and patients had the ability to shop around.”

The team also saw “issues around health equity and access for the uninsured and underinsured, and that was increasing health disparities.”

At this point, Kathrin handed over to Rosemary to present the conclusions from the research.

“This digital maturity assessment in Bermuda clearly showed that it has significant opportunities to develop national digital health information structures,” Rosemary stated. She pointed out that Bermuda is “not alone in the challenges it faces” and said that “in small island states, developing new ways of working together and aligning various stakeholder agendas is an adaptive challenges that requires learning and flexibility.”

She continued: “Technology is the easy part; a large part of digitalisation of health falls in the domain of human factors. In order to track progress and mitigate emerging risks, there will be a need to establish an evaluation strategy that will inform and support the necessary policy decisions around digital health. Commitment to this transition will be essential so that different interests can be balanced, so there is potential to engage stakeholders in order to find creative ways to finance the initiatives.”

Finally, Rosemary acknowledged that the development of Bermuda’s national digital health strategy “gives the country an opportunity to leapfrog and learn from other countries’ experiences”, with the small size capable of presenting a “significant advantage, especially in terms of implementation of infrastructure, information governance and standardisation.”

The drafting of the strategy to follow this assessment is a significant step, Rosemary concluded, “but it is only the first step in an ongoing journey. There is no magic bullet.”

Many thanks to Kathrin, Jay, Alan, Laura and Rosemary for joining us.