​Read Natalie Smith’s staff profile on the University of Queensland Business School’s webpage, and it is immediately clear she has a great sense of humour.

“Natalie has a long and sordid career in technology, starting as a Computer Engineering/Science trainee when screens were green, print paper was perforated and Pacman was considered the pinnacle of gaming technology” she writes.

Natalie has worked as a programmer in a software ‘sweatshop’ (her words); systems engineer with IBM; and technical lead, architect and program manager with PwC.

More recently, she was a partner in Deloitte’s Risk Advisory practice, and Chief Delivery Officer for Queensland Health’s technology branch.

Now at UQ, she is undertaking a PhD on the relationship between corporate governance and project outcomes in digital healthcare, to better understand the capabilities needed to lead and govern digital health transformations.

Her PhD is being supported by top-up funding from the Digital Health CRC.

The first phase of the PhD (the discovery phase, 90% complete) is to understand the extent to which corporate leadership influences the intended outcomes of digital health projects.

Subsequent phases will use the findings from the discovery phase to design and pilot an intervention to support board members and executives in leading transformational change.

Earlier this year, we asked Natalie about her background in digital health, the current state of play in terms of its adoption in Australia, and where she sees it going in the years ahead.

What got you interested in digital health?

My interest started in the Jurassic period when I was leaving school and had trouble deciding between Medicine and Technology. I faint at the sight of blood, so I chose a computer engineering traineeship. From the early 1990s, I realised I could combine Medicine and Technology without keeling over, and I have been doing so on and off ever since.

What real benefits you have already seen from digital health?

We are only just at the start of seeing the real benefits. What technology does really well is break down physical and geographical barriers. That’s exciting in a country like Australia where populations are sparse and distances are vast, particularly for our friends in rural communities. I am also excited by the potential in research. Data is gold for an evidence-based practice like Medicine.

To give an example of direct benefits to both patients and clinicians, you need only look at Queensland. I love hearing stories where the best quality care has been delivered to patients without them having to come into the big metro hospitals. I’m also a long-term advocate of flexible work practices. Medicine is a tough gig on family life. I love hearing about doctors being able to make decisions on patient care, with data at their fingertips, and being able to choose whether or not they need to be physically present at the hospital.

What about instances where digital health could work well…but it either hasn’t been implemented or not everybody has come on-board?

Where it hasn’t worked well there has been an absence of leadership, or a lack of alignment in the leadership team. The analogy I use is that it is like paying someone else to do your exercise and expecting to lose weight. Consultants and CIOs can’t make the change for you. Boards, CEOs and lead clinicians need to own it. Another very consistent theme I am picking up is that the better the alignment in the executive team, and to the Board, the more likely the transformation will be successful. Conversely, the more dysfunctional the corporate leadership, the more likely the change will fail.

Probably my greatest standout story is a health service that was in the news for all the wrong reasons, but decided to push forward with their digital health agenda. There were a million reasons why it shouldn’t have worked, but overall it has helped. Why? Because the CEO owned it and was supported by the Board. They listened to their staff to find out what was worrying them, which helped understand the highest risks. They also selected strong clinical leaders/influencers. They are now reporting a 30% increase in activity without needing to invest more in infrastructure. That’s pretty cool!

What got you interested in the topic of your PhD – was there a ‘wow’ moment when you thought “yes, I need to research this!”

There is never just one moment, but if I had to pick one it was chatting with the chair of a health service that had ‘gone digital’. I asked him how it had changed his role, and he said it had changed everything – from who they recruited as CEO and who they had on the Board, to going to more morning teas than a guy his weight should (his words) and listening to everyone, from volunteers to patients and staff. It had been an all-encompassing transformation of the organisation.

In a previous role, what had struck me the most was that, while complex projects could be delivered successfully, we seemed to be no better at predicting and preventing the failures – this was despite decades of attention to it.

I found I was being asked the same questions when a project was challenged, or an organisation was struggling with their project track rate – questions like “Should we sack the project manager?” or “Do we need to get better project methods or better project tools?” But despite numerous reviews and reports saying similar things, nothing was changing.

I did a few of the Gate 4 assessments for digital hospital go-lives, and the list of questions seemed to miss the heart of what differentiated between success and failure. I talked to some executive teams and clinical leaders who would not let the project fail, and others who delegated the project to the CIO. I knew the role of corporate leaders was critical, but there was very little to guide them or me in those assessments.

So my research became just a bigger version of that “ah-hah” moment, with the saying “you can’t keep doing the same things and expect a different outcome” playing on repeat in my head. I was super keen to work on what we needed to do differently.

What are some of the things you have learned during your research, with regards to attitudes to digital health transformation at a leadership level – what is missing, what is concerning, what is promising, what needs to change and what can be done about it?

Digital health is a game-changer. It is not just going from paper to technology. Technology is highly intertwingled. People to technology, development to operations, system to system, organisation to vendor. It favours consistency and standards. It punishes those who want to be different. It creates huge tensions, for example, on what needs to be standardised and what can be localised – I am only just starting to see organisations get their heads around this.

Some elements of the health system are grappling with digital transformation, in part because of historical power bases, but also because the organisational roles and governance structures around digital health are only just starting to come into place. It means barriers are being lowered between departments of hospitals, medical specialties, levels in the hierarchy, and differences in the level of care (primary to tertiary etc). To some that is threatening, while others are frustrated thinking digital health is only aiming for the ‘lowest common denominator’. The reality is that, done well, digital health brings down these barriers – and it improves consistency and co-ordinated care, which are the foundations for quality and safety and patient-centric care.

Longer term, we will arrive at what technology does brilliantly – that is, mass customisation. An example of that is with our smartphones – the same underlying technology (mostly!) but the ability to personalise it through our selection of apps and accessories. The capability isn’t there yet for the health sector, but it is coming.

In terms of leadership considerations, we need to realise we are not special! Unless there is a super-dooper good reason not to do so, we should go with the ‘standard’ rollout and technologies in terms of digital health. To do that needs strong and aligned leadership and governance. And as I said previously, you can’t pay someone else to do your exercise and expect to lose weight.

Health sector leaders also need to own digital health – CEOs and Boards who think digital health is not their job are an endangered species. What is promising (but is also one of the challenges in getting there) is the “ah-hah” moment when clinicians realise they have to own it, and when CEOs and Boards realise they have to provide leadership. But leading a digital health transformation requires different skills to the ones that might have got them to where they are.

Also, while it might be an oversimplification, it seems to me that clinicians have traditionally focused on doing one thing very well. Digital health requires them to stick their heads up, and work with and lead others. Not everyone is able to do that innately. We need to ‘franchise’ the people who do it well, and we are going to need structural changes to get the right leadership and governance in place.

What concerns you most at the moment in terms of this?

Probably where organisations are not ‘getting’ the operational risks of digital health. The focus has been on getting digital solutions installed. But we need to develop more capability in information management, cyber security, architecture, systems integration and IT service management.

Central IT groups need to become massively more service and customer oriented.

We also need to be much more cognisant of the implications of the intertwingling of digital health in our healthcare systems. This includes being acutely aware of the complexities of changing things once systems are live; the importance of the vendor relationship; and the importance of the user interface.

We can also not afford to be slow in getting the structural changes in place – it can no longer be an ‘every person, division, department, hospital or health service for themselves’ type model.

And crucially, we need to know how to prevent it breaking and fix it quickly when it does. The banks have been doing this for decades – we can learn a lot from them in this area.

Are decision-makers using the right KPIs in terms of digital implementation?

What concerns me are the questions being asked by central government functions, agencies and the media. I have been privileged to work with a number of state health departments and not-for-profit health organisations. Implementing any digital solution is complex, but exponentially moreso in the health sector.

Governments should be proud of what some of the health services are doing and the status we have in the international community. The media like to publish the bad news. But the likes of Princess Alexandra Hospital in Brisbane are standouts in what can be achieved – they did a fantastic job in being the first major metro hospital to go full stack digital.

There is too much noise about having to justify benefits from a business case written by consultants to secure funding (with all due respect to my former colleagues). A government wouldn’t stop building a new trainline or highway halfway through its construction and insist on benefits realisation. It should be no different in the digital space. Like most technologies, the real power of digital health will come when we are all connected with others who are using it. We have just got to go digital. It’s now a WHO directive. Central agencies can slow it down and make it more expensive by asking the wrong questions. Digital health is the only way we can afford healthcare going forward.

Better questions are “How can we get best value from the investment?”, “What are the possible negative impacts and how are they being mitigated?”, “How can we help you build the right capability in information management, vendor management, cyber security etc?” and “What legacy systems, structures and processes are impeding progress and how can we help remove them?”

In undertaking reviews of digital transformation projects and at key decision points along the way, we should be checking that corporate leaders are aligned and owning the change, that they are setting a positive culture and that activity supporting organisational change is funded and resourced. This is at least as important as checking the project is on time and on budget.

What’s your Utopian vision for digital health, and how do we get there?

Ultimately, it will be achieving more holistic, proactive, person-centric care – and taking healthcare to the patient rather than the patient having to get to the healthcare. We’ve already seen this in banking, for example – how long is it since you have been to a physical bank branch?

Finding cures to things that we haven’t yet been able to – because we haven’t had the data – will also be incredibly exciting and rewarding. Already I am hearing that digital health is helping us respond more quickly and effectively to things like COVID-19.*

To get there, we need to get out of our own way. Like any adventure, we need to focus on the purpose, be open to learning from each other, manage the risk and have fun. We also need to question some of the methods and tools we have been using in digital health projects. As an example, we are about to publish a paper on Benefits Management, which looks at the evidence to assess existing methods and suggest alternatives that could provide better outcomes.

We have so much to learn from each other. At the risk of sounding like a soap commercial, it is why initiatives like Digital Health CRC are so important in funding empirical research; communicating what is happening and what we are learning; joining the dots between research and practice; and connecting complementary projects. Digital health can and is being done, and we have a lot we can celebrate.

Outside work, what do you like to do?

My favourite thing is adventuring with family and friends, and doing anything that combines our best with that of nature. I love cycling, hiking, bodysurfing and sailing. I did a cycle trip [pictured] with my high school bestie after a conference in Portugal last year, and absolutely loved it.

Interestingly, even these activities benefit from going digital. There we were, two old chooks able to chart our own adventure in a country we’d never been to before, using a combination of phone apps and other digital services. Thinking of that potential in the context of health is mind-blowing.

Contact Natalie Smith via email at [email protected].

* Natalie was interviewed before the COVID-19 emergency developed in Australia.