Sunday, August 22, 2010

Dr Andrew McIntyre Blogs on The Future For NEHTA in A New Political World.

This has just been posted on the Medical Objects Web Site:

e-Health in Australia – Time to actually move forward!

Well we have had the election and there is no clear winner but it appears that the Rudd/Gillard government is the loser. eHealth is up for some reassessment and it certainly needs some.

From all reports $5 Billion of taxpayers money has been spent over the last 10 years and we have little to show for it. 10 years is long enough for any reasonable plan to bear fruit and there is clearly some fundamental flaw in the methodology.

The decision to purchase a SNOMED-CT license, and a Certificate Authority is the only positive I can find. We do have a Secure messaging standard, but it is flawed by the fact that it really depends on Nehta “NASH” service for suitable certificates rather than working with the existing Medicare certificates. (and NASH is vapour ware) Virtually every general practice has Medicare certificates as part of the PIP program and the reason that the secure messaging standard was not designed to work with them lies with the dysfunctional relationship between Nehta and Medicare.

Dysfunctional organisations seem to be at the heart of the matter. We have not had one organisation for 10 years, but about 4 or 5 each of which has been rebadged and restarted only to repeat the same mistakes. That mistake, or the core of it is the idea that they have to “solve” the problem and produce software. Government is hopeless at doing this, indeed most large organisations are hopeless at producing software and large projects tend to fail. What we need is government to provide governance to move the industry forward rather than trying to do the heavy lifting. After 10 years the things that were working at the start are still working and all the things that are working are based on consensus standards. What we need is governance to comply with those standards and progress the standards in an incremental way. Currently we see much talk of Nehta inventing standards and despite some very capable people inside Nehta this is doomed to failure. Standards have to be created by consensus, as then the industry will engage with the painful standards process in order to prevent silly ideas becoming a standard and to fix errors where they occur. They will only engage when they know they have a duty to comply with the standards and this is where the lack of governance is failing us.

The standards process has become orphaned because Nehta have said they will be dictating the path, and they have failed to produce any clear path. More recently they have tried to steam roll standards and this is also likely to fail as without adequate review the standards will be poor.

Out there is the real world, which is the world that Medical-Objects inhabits, we see significant advances in communication with the number one obstacle being poor standards compliance. Because of a lack of governance large vendors feel that they can flout the standard and dictate the formats though sheer market size. Because of a lack of compliance anything that does work is fragile because it is never quite right, but has to be wrong in exactly the right way in order for it to work.

The dreams of the connected health landscape are often formulated by people with no knowledge of the importance of the lower levels. We can connect to the whole world of internet services because of compliance with the invisible things like tcp/ip and http standards and not because some middle manager dreamed of the internet. The dreams of a connected eHealth world rely on applications supporting the creation and consumption of high quality, standards compliant messages and not on the glossy pdfs produced by Nehta.

I don’t think we need Nehta, the states are not the eHealth leaders in this country and Nehta was setup as an uneasy alliance of the states, many of whom ignore Nehta anyway. What we need is good governance and a focus of standards compliance of all the applications that make up the landscape. There does need to be funding of the standards process and there needs to be a mechanism for providers of healthcare to pay to buy standards compliant software, which is built properly will be more expensive than they are paying now. However, the money they are saving is working against the big picture of a connected landscape and this is where governance and some well directed funding could make a huge difference. If every health application was required to be standards compliant we would see an enormous spike in interest in the standards process and the consensus process could be resuscitated for its premature death and we could start moving forward one level at a time.

The big bang process has failed, as it was bound to do and we need a return to proven paths. The cost would be a fraction of what was planned and the results, though slow would be much more solid. The tortoise is still in the race, it’s time to stop trying to follow the scatterbrain hare!

The blog is found here and is cross posted with permisson:

It will be fun to watch the apoplexy over on the NEHTA Sponsored blog!




Anonymous said...

What a blowhard

Dr David More MB, PhD, FACHI said...

And your knowledgeable well informed comment - rather than pathetic invective is?


Anonymous said...

Andrew McIntyre highlights some very disturbing issues which others have been expressed repeatedly in many different ways over the last many years.

Unfortunately if there were to be any hope of achieving a change in the status quo it well and truly evaporated on Saturday. Neither the Coalition or the Labor Government will do anything much about fixing the ehealth mess as they have far greater distractions of monumental import now on their plates.

On Friday NEHTA circulated its BLUEPRINT for EHEALTH.

On page 8 I read:
"The primary purpose of NEHTA is to support the national agenda for e-health by leading the uptake of e-health systems of national significance ..."

On page 9 I read:
"In moving forward NEHTA will seek to drive the adoption of a range of new healthcare capabilities across the sector. These capabilities include *Foundations and * E-Health Solutions. .....

Implementation of these capabilities will be supported by a change and adoption program which enhances engagement and collaboration across the key stakeholder group; ... "

None of this gave me much confidence; it was the same old stuff brushed up and regurgitated from pre-NEHTA days when DOHA was in charge of the original HealthConnect project. Andrew McIntyre's comments undermined my confidence still further.

But my confidence was shattered to smithereens when I read:

On page 16 ... "Strategic priorities are measured by the success of their associated underlying strategic initiatives."

and again, ..... "Each initiative contains a specific set of actions and defined owners, and is used to measure success against its associated strategic priority."

These last two 'statements' epitomized for me what Andrew meant when he wrote:

"Dysfuntional organisations seem to be at the heart of the matter."

nothing has cnahnged and nothing will chan

Anonymous said...

Yes, absolutely, and dysfunctional organizations are dysfunctional when the management has no idea that the sort of rubbish which appears on Page 16 of the NEHTA Blueprint is meaningless hokum pokum.

Anonymous said...

And I read NEHTA's Blueprint too. Have a look at Sections 4.3 Referral, 4.5 Diagnostic Imaging and 4.6 Discharge Summary. It reminded me of what Karen Dearne wrote on 15 June about Labor's ehealth spendathon - "THE Rudd government will spend a whopping $639,315 each and every day on "personally controlled" electronic health records".

What was it that reminded me of the $639,315? It was:

4.3 Diagnostic Imaging
is at the "inception" phase - "currently in a phase of building concensus with stakeholders"

4.5 Referral
is at the "requirements analysis phase" - "currently in a requirements collection phase"

4.6 Discharge Summary
is at the "design phase" - "currently in a phase of profiling standards based on concensus with stakeholders on the requirements and design".

How many people does NEHTA employ? 200, 250, more maybe?

What have they been doing year after year after year?

What have they delivered?

I agree with Andrew McIntyre - "The decision to purchase a SNOMED-CT license and a Certificate Authority is the only positive I can find."

Is it any wonder the vendors despair?

Anonymous said...

Hey - it's not just the vendors despairing everyone (vendors, politicians, service providers, stakeholders of every ilk) is despairing except NEHTA.

Anonymous said...

Andrew said "The standards process has become orphaned because Nehta have said they will be dictating the path, and they have failed to produce any clear path. More recently they have tried to steam roll standards and this is also likely to fail as without adequate review the standards will be poor."

NEHTA makes its position pretty clear in its Blueprint (global search for STANDARDS). In its BLUEPRINT NEHTA says "NEHTA has worked with the medical software industry to develop specifications and standards for secure messaging for healthcare providers."

And NEHTA also says "NEHTA will work with the sector on promoting a standards-based approach to
Medication Management so that prescriptions may be securely shared between a prescriber’s system and the dispensing pharmacy of the individual’s choice."

In regards to Secure messaging NEHTA says "The specification for secure message delivery has been completed and
a technical specification is now available through Standards Australia."

On HL7 NEHTA provides the following comments:

"HL7 v2 is currently the predominant means of communicating atomized health information electronically in Australia. Non-atomized data is commonly sent using paper letters, faxes, emails and PDFs. In some cases, HL7 v2 messages are used to help route the content and the PIT format is used to provide a human readable version of the content.

HL7 v2 is effective for traditional message-based interconnectivity applications within ICT environments where both the sender and receiver
work within a common agreement. Its capabilities also continue to be extended. It also has a large community support in Australia and internationally, its current range of uses is well supported by existing infrastructure, knowledge, tooling, consulting services and implementation

Notwithstanding these benefits, there are a range of internationally acknowledged problems with the HL7 v2 standards that is hampering interoperability, including:

“The HL7 v2.x development process is entirely ad hoc. There is no explicit methodology. Members receive no formal guidance in constructing messages. Trigger events and data fields are described solely in natural language. The structural relationships among data fields are not clear. Segments are reused in many messages and message definitions are reused for many trigger events. In order to accommodate this extensive reuse, most data fields are optional.
Chapters are inconsistent in their use of trigger events versus status codes. There is no specification as to when a specific kind of healthcare information system should be expected to honour a trigger event or
accept a message.

With v2.x, a Work Group creates messages by editing word processing documents directly. The metadata is not available in a structured form until the staff and volunteers tediously extract it from the word
processing documents after publication.

In summary, there is substantial need to improve this old process in order to handle the breadth and complexity of the challenges HL7 faces today. Our industry will benefit because this new process results
in a more rigorous specification. “ (from HL7 v3 specification)"

On short it appears that Andrew McIntyre and NEHTA are at logger heads.

Who is right?

Andrew McIntyre said...

I guess I am just impatient. This is how wikipedia starts in describing HL7 V3:

"The HL7 version 3 standard has the aim to support any and all healthcare workflows. Development of version 3 started around 1995, resulting in an initial standard publication in 2005. The v3 standard, as opposed to version 2, is based on a formal methodology (the HDF) and object oriented principles."

The important thing is that was said in 1995 and its still not ready for prime time. 10 years and 5 Billion later and its not ready for Australia either. After 300 Billion its not working in the UK.

Surely a pragmatic approach to "Move Forward" with what we have standards for ie: HL7V2 while we work on the Holy Grail in the background is reasonable at this point.

If HL7 V3 is any good then it will mature and quietly replace V2 "In Due Season" Its like refusing to drive a car until its powered by a Hydrogen fuel cell.

Anonymous said...

The other recent publication on the NEHTA RSS feed "Draft national approach to pathology services" is yet another example of NEHTA inventing standards. There are already lots of standards around Pathology workflow. Why do we need another one from NEHTA?

Anonymous said...

I believe that Andrew's objection to SMD is mainly that S/MIME is not a mandatory part of the standard. The certificate issue is complex, not just a matter of NASH or Medicare Location Certificates. It also depends on what toolkit is being used for web services.

NEHTA has, however, failed to deliver NASH for almost its entire history.

Dr David More MB, PhD, FACHI said...

And according to the Blueprint is still designing it with no delivery date defined. How many years it is they have been promising this. Too many is my view!


Anonymous said...

Andrew, (Monday, August 23, 2010 3:28:00 PM)there is no need to apologise, you are anything but impatient - 1995 was a long time ago.

I find it impossible to comprehend why NEHTA wants vendors in Australia to adopt its idealistic view of the world. As you so rightly said:

“surely a pragmatic approach to "Move Forward" with what we have standards for ie: HL7V2 while we work on the Holy Grail in the background is reasonable at this point.”

As a lawyer I like to apply the ‘reasonable person test’ and in doing so the only conclusion I can come to is that - you are a reasonable man.

Further, a reasonable position to take is (as you say) “If HL7 V3 is any good then it will mature and quietly replace V2”.

The corollary therefore is that NEHTA, or some influential individuals inside NEHTA, are not being reasonable. If we understood their personal motives then we would understand how to resolve a complex situation which they seem intent on perpetuating.

Anonymous said...

antiquated technology and their proponents (AMc) are the boat anchor for the health sector

Dr David More MB, PhD, FACHI said...

A bit of a pity HL7 V3 still struggles for major adoption then. I assume you are fully using V3 successfully - and if so you can say who you are so you can assist us all!

If not then would you like to justify your position?

Feel free to send me a post for the blog!