Friday, December 31, 2010

A Piece of Sanity Emerges on New Year’s Eve. Change is Now No Longer Optional - It is Critical!

Good Heavens! It seems there is some sanity in the bureaucracy. Maybe they should act on their anonymous musings!

This was posted a few hours ago, but was so far down among the 32 comments I thought it was worth highlighting!

The original blog is here:

http://aushealthit.blogspot.com/2010/12/it-isnt-only-wikileaks-that-can-cause.html

Anonymous said...

What very very interesting comments by Andrew McIntyre said... Tuesday, December 28, 2010 12:35:00 PM.

Hopefully they will be widely read and hopefully others equally well informed will support or counter these views.

I am not deeply enough involved in the issue to enter the argument but as a senior manager in health and heavily involved in setting directions and strategies for eHealth nationally I have to make my judgment calls on the advice of my 'techo' experts who each have their own biases and differences of opinion.

Having said that as I contemplate Andrew's comments I ask myself (a) will we ever get 'there'? (b) why aren't we drawing more on the expertise of people like Andrew with years of experience at the coalface? (c) how can I rely on the advice I am given by so-called 'experts' in my organisation who are relatively new to the field? (d) how can I better direct the large sums of money available to get better results and outcomes and working interoperable systems in the field?

Questions like these are at the forefront of my mind every day of the week - in short - are we approaching the problem the right way or should we be doing things differently and in what way?

Thank you Andrew for your very interesting comments.

Friday, December 31, 2010 9:12:00 AM

This was in response to this post from Dr Andrew McIntyre.

Andrew McIntyre said...

While it is common for people from other parts of the IT industry to look for an xml solution I am not sure that xml solves much.

HL7V2 predates xml and its very terse and efficient and this can be an advantage wrt storage and latency and the data is much better being machine readable rather than human readable. HL7V2 is at least text and can be read by humans but I almost never do that.

The bigger problem is the modelling required once the encoding issue is dealt with and in reality this is 99% of the problem. HL7V3 was started in 1992 and HL7V3 messaging would have to be called a failure after 18 years of effort with no results. However HL7V2 continues to grow and prosper and can be enhanced to carry high level semantics in a backward compatible way and this is the path I still think is the most likely to succeed.

CDA is xml but offers little advantage over good HL7V2. You may not need to write a xml parser but the advantages mostly finish there and you just get a document and no messaging semantics, so it cannot replace V2 alone!!!

There is nothing that can't be done with HL7V2 done well and I think it’s the tortoise in this race. Its functionality is quite mature in many areas and combining it with Standards based Archetypes leads to a very solid solution that is backward compatible. The issue is that new people tend to read the V3 specs and ignore V2, and then deride it out of ignorance. It’s a solution that keeps growing while V3 is the playground of Ivory Tower Architects with virtually no implementations of V3 messaging that actually work on any scale.

Tuesday, December 28, 2010 12:35:00 PM

And moments ago we had this devastating stuff from a senior ex-NEHTA employee who also sees the need for some pretty radical change:

Eric Browne said...

Anonymous of Friday, December 31 2010 9:12am asks a number of good questions at the forefront of his/her mind every day of the week.

If similar questions are reflective of the e-health management community more broadly, then I would contend that we have the wrong people making such decisions. Such decisions require a deep technical knowledge and considerable engineering knowledge and experience.

I think the principal reason why more isn't made of the experiences and knowledge of the likes of Andrew McIntyre is due to the closed nature of NEHTA. Instead of providing a forum where important technical approaches could be debated and evolve, we have had a situation, initiated under Reinecke, but continued under the present regime, whereby parts of the e-health infrastructure are developed behind closed doors and announced by decree, in the absence of a comprehensive and coherent strategy that can address all the missing pieces. And without a realistic timeframe and strategy for adoption.

There is clearly a shortage of technical skills in e-health in Australia and very little money is going into addressing this skills shortage.

As to the specific issue Andrew raises in support of HL7 v2, I would contend that both v2 and v3 have fundamental shortcomings that inhibit interoperability. In both cases, they rely extensively on external vocabularies to label nearly every data node in message or document. In the Australian messaging standards that have been produced to date, the vocabularies have not been satisfactorily agreed; the vocabularies that have been mandated (e.g. LOINC and SNOMED CT) have major shortcomings; there has been no adequate distribution mechanism established for incorporating and updating these in clinical systems; there has been no adequate conformance and accreditation regime put in place; very little attention has been given to developing agreed clinical models, to the point that there is NO STANDARD way of even representing blood pressure in HL7 v2 or V3.

In short, I think we should be doing things differently. And I, too, would welcome further views on the issues Andrew raises.

Friday, December 31, 2010 10:58:00 AM

So what we have here are bureaucrats being advised by people they don’t trust and who they suspect are pushing very narrow barrows, while the real experts are just sidelined and disempowered.

Great isn’t it?

The present structures will never deliver and need to be changed. Additionally all the bureaucrats who are responsible for e-Health but are being bamboozled by 'techies' need to do something, and quickly, about their sources of advice. The inevitable failure of the PCEHR is not something that would look good on the resume!

Suggestions as to how that may be made to happen welcome.

David.

Postscript:

Look out early in the new year for a blog highlighting the abysmal and now fully documented failure of the NSW HealtheLink project!

D.

6 comments:

Anonymous said...

Eric Browne said on Friday, December 31, 2010 10:58:00 AM
... there has been no adequate conformance and accreditation regime put in place; very little attention has been given to developing agreed clinical models, to the point that there is NO STANDARD way of even representing blood pressure in HL7 v2 or V3.

Among other things Eric also contends, in response to Andrew McIntyre, that both v2 and v3 have fundamental shortcomings that inhibit interoperability and that vocabularies that have been mandated (e.g. LOINC and SNOMED CT) have major shortcomings.

This discussion is most interesting and, at the same time, quite disturbing.

Reflecting deeply upon the positions put by these two highly qualified experts I wonder whether, if we brought such experts together, we would make any more progress or just create another difficult problem in how to resolve the fundamental differences of opinion between a cohort of experts as these!

I understand their views and as far as I can tell they are probably both quite correct. So often I listen to the views (often referred to as the sales pitch) of big vendors such as iSoft, InterSystems, IBM and Cerner. They all have a common end point to their pitch …. a national integrated interoperable health system focussed around a PCEHR which most people seem to refer to as Person-Controlled, but which at the upper echelons of government we prefer to think of as meaning Person-Centric with a limited degree of Personal-Control.

I see too that the well established vendors have the benefit of extensive experience gained from their broad customer bases in many countries and substantial R&D facilities. They describe this as a proven track record but I wonder to myself how can they all reach the common end point, at least here in Australia, if they do not cooperate with each other along they way?

This seems to me to be the fundamental problem – a problem emanating from multiple competitive vendors, all coming from different starting points, all claiming to be heading in the same direction, combined with a troubled ever changing health care environment with no standardised infrastructure in place upon which to build and implement a model of the health system which all the rhetoric so consistently describes.

I have observed the outcomes in the United Kingdom, I have seen iSoft tumble from its perch, and I watch in amazement at the multitude of fragmented approaches being cobbled together across 30 or more states in the USA. I am aware that here in Australia we have not made a great deal of progress, indeed we have some costly failures scattered hither and thither to remind us of that. Even so I am reassured that we are in a position to be able to move forward cautiously and perhaps attempt to implement a model infrastructure or two upon which to cement into place some standardised applications that can act as a basis for overcoming the fundamental shortcomings that Eric Browne and Andrew McIntyre continue to wrestle with.

Anonymous said...

This has been posted before, but needs to be repeated in this context as this has been the problem in eHealth for the last 10 years:

"Progress, far from consisting in change, depends on retentiveness. When change is absolute there remains no being to improve and no direction is set for possible improvement: and when experience is not retained, as among savages, infancy is perpetual. Those who cannot remember the past are condemned to repeat it."

Nehta has tried to invent standards from the ground up and have failed dismally as you would expect. We do not need an outside person to come in and show us the way. The interoperability that we have wrt lab data is at a high level, even if it has significant warts. We need to build on that success.

Currently the PCEHR makes no reference to the HL7V2 lab data that would populate much of its information.

We have an attempt to implement medication management with a document format (CDA) - which is a very poor choice for a transactional problem.

I think there is a sense of desperation within Nehta and its almost fanatical in its opposition to what's actually working. We have a V2 Medication standard that details nearly 100 transactions but we are going to dump that for CDA specification that does one transaction badly???

That reminds me of another George Santayana quote:

"Fanaticism consists in redoubling your efforts when you have forgotten your aim."

NEHTA have become fanatics to impose their will even when everything they have done to date has failed. That's eHealth terrorism.

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

Here is an e-mail I just sent to a player in the area:

"You know I believe the key is to get a governance framework in place that gets all the various actors in the room (figuratively) to discuss, debate and be facilitated into working out what is needed, how it can be achieved and how it will be delivered and funded.
 
This is going to mean getting rid of the ways both DoHA and NEHTA are currently operating and providing an utterly different form of leadership.
 
This will only happen when Ms Roxon and Ms Halton realise that the present course they are on actually constitutes and existential threat to their futures. If you think they are on the right track then nothing need be done - if you believe otherwise then we need to work out some way to act for all our sakes!
 
Right now all we have is a gold rush led by people who don't have a real clue as to just how hard what they are attempting is. In time they will realise the UK provided real lessons among others.
 
The governance model in the US is one example where things seems to be happening in a much more rational way.
 
All my experience tells me this PCEHR is heading for disaster. The NSW Healthelink project has now essentially imploded with 60+% of the practices involved leaving and the volumes of messages now at 20% or so of the peak.
 
I predicted this in 2006 (see blog - search healthelink) - so I have a certain credibility on this sort of stuff.
 
As you can see from the blog there are a number of real experts who agree with my perspective and who are just excluded, for no good reason, from the debate."

Time for real change in this game I reckon!

David.

Anonymous said...

My god this concerns me!

"I have to make my judgment calls on the advice of my 'techo' experts who each have their own biases and differences of opinion."

Since when has being non-technical allowed our leaders to abdicate their responsibilities to form a properly conducted program based upon need, agreed requirements from the business as well as the "'techo' experts", and end to end traceability.... ?

Anonymous said...

Wow, thank you for this honest posting, and explaining the realities of making decisions in the current non transparent government setting.

My observation - if you don't understand the details of what you are in charge of, then you by definition can't make good decisions.

The reason you don't understand, I'm betting, is not that you are incapable of understanding (clearly the contrary), but that the internal 'techo' experts that you are reliant on are not as expert as they profess.

A real expert will make it all crystal clear for you, and never ask you to 'just trust me on this'. Their deep understanding of the domain will allow them to reframe concepts in simple ways, and they will never hide behind detail or complexity, which is the final refuge of those out of their depth.

Please, please, find new experts!!! Find people who have experience, and courage, and will 'speak truth to power'.

Anonymous said...

"This seems to me to be the fundamental problem – a problem emanating from multiple competitive vendors, all coming from different starting points, all claiming to be heading in the same direction, combined with a troubled ever changing health care environment with no standardised infrastructure in place upon which to build and implement a model of the health system which all the rhetoric so consistently describes."

The basic problem is that there is a complete lack of understanding of the complexity of the health sector - and any so called 'model' approach is doomed for failure. The variety of individual consumers, providers, agencies & funders, coupled with the range of competitive and mercenary attitudes (including none) means that trying to put together complete a e-Health solution in any sort of timeframe less than a generational change (or two) is not going to work but is going to line a lot of pockets on the way.

Luckily, at this stage (unlike the US), all this e-Health activity has not actually harmed the ability to provide patient care in a more effective and efficient manner although it has tarnished clinical leaders in trying to deal with decision makers who actually control nothing!

Very interesting reading all these blogs!