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Fostering PPP in the Hong Kong Healthcare System Print E-mail
The Quarterly 2011


Background
Hong Kong, a world-class metropolis which more than seven million people call "home", is, in common with many other communities, facing a raft of challenges in its healthcare system. In order to keep pace with the rising healthcare costs and expectations whilst safeguarding health service quality for its citizens, it is crucial to create a mutually-supportive network that sustains and continuously improves through collaborative efforts of public, non-governmental, and private healthcare providers.

In a Hong Kong think tank’s final report "Development and Financing of Hong Kong's Future Health Care" (2007)1, it stated that "many governments are contemplating or implementing initiatives to reform their health care delivery and financing systems to respond to changing needs and demands". Being a vibrant city where the healthcare system maintains some of the best vital statistics and performance measures in the world, Hong Kong is no exception.

While supporting continuous improvements in public health services, the Government of Hong Kong Special Administrative Region (HKSAR) has also pioneered new healthcare projects based on the concept of Public-Private Partnership (PPP). Although joint efforts by both public and private healthcare bodies have proven to be helpful in alleviating the society's healthcare burdens, operation of the PPP projects requires careful planning in order to facilitate smooth implementation. To ensure project effectiveness and enhance sustainability, every detail and potential obstacle has to be thoroughly thought through and explicitly investigated, as many are novel pilots in the Hong Kong context.

The Role of PPP in Hong Kong Healthcare
The Hospital Authority (HA) of Hong Kong is the statutory body that manages all 41 public hospitals, 48 Specialist Out-patient Clinics and 74 General Out-patient Clinics, in Hong Kong. At the same time, there is a high quality private medical sector that has about half of Hong Kong’s medical manpower, and growing resources. The public hospitals and clinics in Hong Kong are grouped into seven geographical clusters. It is well recognized that the increasing demands in Hong Kong’s healthcare environment cannot be met purely by increasing frontline public manpower or resources. Greater collaboration between public and private sectors is another important factor.

As defined by the Efficiency Unit of the HKSAR Government (2005)2, PPP refers to "arrangements where the public and private sectors both bring their complementary skills to a project, with varying levels of involvement and responsibility, for the purpose of providing public services or projects". To minimize discrepancies and interruptions arising from practice variance and work cultures, close collaborations and good communication between the public and private sectors is indispensable in adopting a PPP model in an efficient manner.

PPP projects in healthcare can help maximize use of clinical resources and encourage exchange of medical expertise between the public and private sectors. More choices can be offered to public patients, and limited clinical expertise shared more efficiently between the two sectors.

The Sharing of Electronic Health Records as a Prelude to Clinical PPP Projects
Even though the HA's Clinical Management System (CMS) manages more than eight million electronic patient records, such CMS information is currently confined within public hospitals and clinics. To address the need for a comprehensive health record system, the HKSAR government had in 2009 set out its decade-long plan to create a territory-wide, patient-oriented Electronic Health Record (eHR) Sharing System which would serve both public and private sectors3. The eHR sharing system can benefit the patients by avoiding unnecessary repetition of investigations, minimize chance of treatment delay, and save time. It will ultimately improve the overall healthcare quality.

With professional advice and expertise from the healthcare, information technology, and legal fields, the first stage of the eHR Sharing System is planned for execution in 2013 – 2014, five years after the initial plan was formulated. The electronic record sharing platform helps the healthcare professionals to access their patients' complete medical records subject to authorization and consent. Apart from viewing, the latest health record of individual patients can also be uploaded for future sharing among authorized users.

For PPP projects to safely, reliably, and efficiently transfer patients' medical information from the public to private domains, it is fundamental that an efficient sharing mechanism for medical records exists among various healthcare providers. Sharing of the patients' information helps to maintain full chronological profiles of their medical history, thereby enhancing continuity of care.

In the long run, piloting of the PPP projects prepares the healthcare system for eHR sharing under the future healthcare reform model, and it has marked a cornerstone in the entire eHR development. Although the PPP projects differ from one another in their operation and targets, they all involve patient electronic record sharing. As the projects rollout, healthcare professionals become more familiar with the convenience of sharing patient records electronically across sectors.

It is worthwhile to bear in mind that whether it is the PPP project or the future eHR Sharing System, sharability of all patient's confidential information is only on a need-to-know basis. Under all circumstances, the strictest of privacy protection and IT security controls apply.

Successful PPP projects, relying on mobile patient records, where "records follow the patient", is an important catalyst for promulgating the eHR project to the private sector. From the operational perspective, the PPP projects can also be used as the pilots to determine the technical feasibility of the data sharing mechanism. Any shortcomings of the systems can be attended to and given time for rectification. This will again prepare for a smooth implementation of the eHR sharing system in 2013 - 14.

Some Clinical PPP Projects in Hong Kong
Some of the PPP projects that have been initiated in Hong Kong include:

I. Public-Private Interface Electronic Patient Record (PPI-ePR) Sharing Pilot Project (Launched since 2006)
The project marked the earliest implementation of PPP notion in the healthcare system. Rather than being a program that focuses on specific treatment delivery, the PPI-ePR project provides an IT platform for the patient's health information to be shared from the HA system to those of the private and non-governmental sectors.

With the patients' consent and user authentication, the PPI-ePR project allows participating healthcare providers in the private and non-governmental sectors to view their patients' medical records kept in the HA. Based on the records retrieved, information accessed could be used as reference for clinical decisions and treatment orders by non-HA doctors. As at October 2011, over 175,000 public patients and 2,400 private health service providers have joined the project, as have all the private hospitals in Hong Kong.

II. Cataract Surgery Program (CSP) (Launched since 2008)
This novel program was seen as one of the most successful PPP projects that demonstrated the importance of bringing innovative thoughts to traditional services. Eligible public patients are subsidized under a co-payment mechanism to undergo cataract surgeries in private hospitals. Over 10,000 patients have participated as at February 2011.

Rather than just offering "read-only" access to the patients' medical records kept in HA, this program allows the participating private healthcare providers to enter clinical notes of their patients for follow-up by HA doctors. The launching of CSP has significantly reduced the waiting time of public patients for cataract surgeries.

III. General Out-patient Clinic Public-Private Partnership Program (GOPC PPP) (Launched since 2008)
Through subsidy arrangement by the government, patients only need to pay the usual GOPC fees when using consultation service at the participating doctors in the private sector. By choosing a particular general practitioner who had voluntarily joined the project, patients could be looked after by a chosen family doctor.

This project also allows the general practitioners to enter data in the patient's medical history electronically, thereby building continuous records for the patients. Such an arrangement was particularly useful for chronic disease patients who may need to later return to HA hospitals and clinics for specialist follow-ups.

IV. Radiological Image Sharing Project (Launched since 2009)
Through infrastructural arrangements in the computerized imaging sharing system, private radiological centers can send radiological images of the enrolled patients electronically back to HA institutions. The sharing of radiological images from the private to the public sector helps timely transfer of information and avoids unnecessary repetition of radiological examinations.

V. Patient Empowerment Project (Launched since 2010)
Through collaboration between HA and various NGOs, the project aims at improving the knowledge of patients with chronic disease to better manage their own health. A HA multi-disciplinary team comprising various allied health professionals, developed teaching materials for common chronic diseases and provided training for frontline staff of the participating NGOs. The Patient Empowerment Program4 has a target of serving over 30,000 patients in three years.

Considerations in Running PPP Projects
Although the PPP Projects have yielded marked success and gained support from various patient groups in the Hong Kong community, the road to their implementation is not without hurdles. Intense efforts are needed to consider factors such as the actual demands, feasibility, public's acceptance, outcome measures, evaluative means, etc, before working out the individual PPP projects. In particular, careful considerations have to be made in working out the directions and tailoring details of PPP projects in order to achieve maximal returns. Any miscalculations could lead directly to ineffective implementation, resource wastage, or, in worse situations, healthcare risks.

Before deciding on the types of PPP projects to develop, it is firstly essential to carry out detailed investigations on what the public really needs. Stated by Preker and Harding (2007)5, it is important to get "the fundamentals right" in defining health service areas that could be addressed by using the PPP model. In fact, the allocation of resources in PPP projects requires not only clinical expertise, but also tactful arrangements in ensuring cost-effectiveness in financing the projects, generating inputs, and providing the services.

Arrow (1980)6 commented that all types of public interventions involves transfer of benefits to some parties and costs to others, the outcomes of any activity are always "winners and losers". The tactic for running PPP projects, therefore, is to strike a balance between the "gains" and "loss" by determining the worthiness of efforts.

Secondly, gaining the public's trust and support is also of high level importance. In fact, behavioural changes among the users often influence whether PPP projects succeed. Any deterring factors that lead to hesitation of the public to use the services could impact the overall utilization rate of the projects. Analyzing the reasons of oppositions from the stakeholders and general public could therefore help to formulate the direction for PPP project development.

While it is important to gain cooperation from the existing healthcare professionals in the public arena to introduce PPP projects to suitable patients, ensuring quality of service provision from the private sector is also important. Hence, the third determining factor for the success of PPP project is about choosing competent and reliable partners in service provision. Any inconsistency in service delivery from one sector to another can adversely affect the entire PPP outcome.

Fourthly, it is important to establish a comprehensive set of legal frameworks that govern the running of PPP projects. Suggested by Grimsey and Lewis (2004)7, the lack of a well-established legal framework could lead to disputes. In the healthcare domain, PPP projects exert pressure onto the local healthcare system. As the traditional means of case management methods and protocol may not be effective in joint care delivery, there might be loopholes in areas once thought to be foolproof. Thus, the professional responsibilities and legal liabilities must be carefully defined in running PPP projects.

Last but not the least; risk management must not be neglected. Since the impacts of healthcare projects are often huge and sometimes life-threatening, the operational risks must be minimized as far as possible. Just like any other healthcare programs, risk assessment and identification play an important role in the quality and safety aspect of the PPP projects. Sufficient risk management mechanisms must be kept in place to ensure optimal levels of service standard and patient safety. To avoid overlooking the risks, both the private and public health sectors should work together and have a good understanding of risks that pertain to joint care management. Through a reasonable risk allocation and minimization strategy, the projects can be more safely rolled out.

Conclusion
To successfully implement future PPP projects, it is essential that engagement and participation is diligently earned from all stakeholders in the private and non-governmental healthcare providers. In particular, taking into consideration the sometimes different concerns of multiple stakeholders on a case-by-case basis can help to tailor-make relevant PPP projects that yield optimal outcomes and bring about a win-win situation to all participating parties.


Mr Sai-yen Chan
Executive Officer I (eHR Engagement Initiative), Hospital Authority Information Technology Services, Hong Kong Hospital Authority

Dr Khai-meng Choy
Chief Manager (Service Transformation), Hong Kong Hospital Authority
Consultant (Public-Private Partnership), Food and Health Bureau, Hong Kong Special Administrative Region

 

Disclaimer
The views of the authors are personal, and do not seek to represent the views of the organizations they serve.
References
1. The Bauhinia Foundation Research Centre Health Care Study Group. 2007. "Development and Financing of Hong Kong’s Future Health Care – Final Report". Hong Kong.

2. (Online Resources) Efficiency Unit. HKSAR Government. 2005. "PPP Overview", Available at: http://www.eu.gov.hk/english/psi/psi_ppp/psi_ppp_over/psi_ppp_over.html (accessed on 3 October 2011)

3. (Online Resources) Information Services Department. HKSAR Government. 2009. "Press Releases: Government launches Electronic Health Record Engagement Initiative", Available at: http://www.info.gov.hk/gia/general/200910/08/P200910080116.htm (accessed on 25 October 2011)

4. (Online Resources) eHealth Record Office. Food and Health Bureau. HKSAR Government. 2010. "Patient Empowerment Programme", Available at: http://www.ehealth.gov.hk/en/ehr_related_projects/sharing_pilots/patient_empowerment_programme.html (accessed on 28 October 2011)

5. Preker, A. S., Liu, X, Velenyi, E. V, and Baris, E. 2007. "Public Ends, Private Means". Washington DC:The World Bank.

6. Arrow, K. J. 1980. "Arrow's Theorem: The Paradox of Social Choice". New Haven, CT:Yale University Press.

7. Grimsey, D. and Lewis, M. K. 2004. "Public Private Partnership: The Worldwide Revolution in Infrastructure Provision and Project Finance". Gloucester: Edward Elgar.

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