Currently, the required degree of alignment of shared leadership and appropriate governance arrangements, across the many areas of responsibility, needed for systems synergies, are limited. Program management is equally important to project management to ensure shared learning of technical and interpersonal expertise.

Although health reform agendas mean to streamline policymaking and funding models, many stakeholders consider that very little has really been achieved that delivers any significant improvements into the way health systems operate. In this context, there are significant funding and resourcing pressures on any given state/national health system. The nature of these pressures unfortunately means that the focus reverts back to a business-as-usual paradigm within health systems. Furthermore, the current budgetary and operational pressures on the health sector restrict the ability of leadership within the sector to respond to contemporary challenges.

Existing and complex regulatory environments are viewed as a major issue where very little practical and beneficial change has been able to be introduced.

It is recognized that significant progress has been made in reporting/compliance arrangements and systems that are focusing on transparency and accountability of health-care service providers. Given the current widespread lack of active use of data standards utilized within the fragmented health ICT ecosystem, it is difficult to harness the big data opportunities inherently available in health-care performance metrics (10). As such it is neither feasible nor practical to be able to use performance metrics to assess productivity in meaningful depth that could introduce transformative efficiencies into service delivery models.

Globally, there is much valuable work on developing open standards in health, for example, Ref. (11, 12). However, there remain many challenges in their widespread adoption related to limited funding, limited leadership capacity, widespread agreement, and limited workforce skills and resources. A particular issue concerns the focus on data collection and data entry rather than what we refer to as a more holistic approach to data management including the purposeful application of collected data to improve health outcomes.

A significant barrier to the successful deployment of new systems is managing the transition from legacy ICT systems and data management processes in delivery of health services. This has further exacerbated the disparity between implemented ICT solutions and the business models and processes, which they purport to support. For instance, the procurement processes of health ICT solutions should be continually reviewed and iteratively refined along the dimensions of digital disruption, accountability, risk assessment, risk mitigation, risk averse strategies.

Evidence of potential suboptimal processes is highlighted by the patient journey through the health system, which invariably spans organizational and operational boundaries whose systems are typically not seamlessly connected to support the overall delivery of health care (9). In the case of rare disease diagnosis, a patient’s navigation through the health system is referred to more as an odyssey than a journey (3).

In addition, business model and process reform which is required systemically throughout the health system and much of which depends upon regulatory reform, is considered one of the most significant barriers to any beneficial transformation of the health system.

Sociotechnical complexities (complexities that span societal and technical boundaries) are inextricably linked to many aspects of business models and their associated business processes. Many of these complexities are inherently cultural in nature, in so far as many health workforce participants operate within long standing conventionally designed systems ecosystems. So while some progress continues to be achieved in specific situations, the big breakthroughs can only be achieved through large-scale business model and process reform as driven by regulatory change. If these are not addressed, then, for example, emerging trends such as patient empowerment via the measured self (13), the Internet of things (5), and personalized medicine will only see these complexities exacerbated (14).

Another key aspect of this concerns a real focus on business models, business processes, and systems, which collectively enable much more community engagement at all levels in consultation on matters such as prevention, patient care, diagnosis, treatment, management, privacy, and consent.

Technical and communication infrastructure is no longer viewed as the major issue as it was in recent times. It is clear that more effort needs to be made to connect existing infrastructure components to enable better communication between health-care service providers and so achieve more coordination of services.

A barrier to success exists in the form of limited staff capacity across a range of administrative, clinical, research and technology disciplines to overcome the significant business-as-usual pressures of national health systems. This must be addressed to implement transformative change. ICT systems inherently can track performance, which can give rise to fear of inappropriate exposure for suboptimal clinical decision-making.

There are limited virtual spaces where the health sector can interface with the research sector. Health departments do not have infrastructure to provide analytic environments for their big data, academic environments are typically not structured to handle health data, despite possessing the analytic capabilities.