Thursday, July 21, 2011

It Looks Like Desperation and Heavy Tactics Are Now Taking Over the PCEHR Program. Not Good!

In the last few days some quite alarming stories have been coming to me regarding the relationships between NEHTA, DoHA and the IT-14 Committee of Standards Australia.

The drivers seems to be a rising desperation and frustration with the fact that Standards Australia is the sole national entity that can agree and approve national e-Health Standards. The feeling seems to be that the traditional methods of volunteers working to develop Standards is simply too slow and inefficient and that NEHTA needs to take over the process and drive it forward more rapidly and in a more focussed way.

Apparently at issue now is that if Standards Australia does not agree to much more NEHTA control of the Standards development process that the current agreement between DoHA and Standards Australia for funding of the work will not be renewed - with some threat to the jobs of the staff who are presently doing this work.

Needless to say Standards Australia (as a commercial entity) is not exactly thrilled by these sort of ‘heavying’ tactics.

Driving all this is the desperate need to meet the ridiculous time lines for development and delivery of the PCEHR which have been announced by Minister Roxon and which seem to NEHTA and DoHA to have no flexibility.

The worry is, of course, that Standards are meant pieces of work which are capable of straightforward and reasonably easy implementation when done by industry experts. Sadly what NEHTA / DoHA want approved as Australian Standards have, I am told, never actually been implemented.

Many of the volunteers are said to be concerned that a push for full HL7 CDA adoption, and the progressive phasing out of HL7 V2, is both premature and risky given the unproven and complex nature of CDA implementation. It might turn out that NEHTA’s CDA’s plans are just wonderful, but it would be good to see some large-scale successful implementations elsewhere before we de-commission our V2 messaging infrastructure. The precautionary principle applies here.

Grahame Grieve’s suggestion of using the V2 Infrastructure to Phase in CDA messages (transmitted and wrapped in V2) also seems reasonable and also allows for a planned and managed transition.

See here for more detail on this:

http://www.healthintersections.com.au/?p=392

A number of people are now telling me that things are getting pretty tense and heated.

All I can say is ‘watch this space’. It can only be a matter of time before the tensions between those who think that they should do a ‘proper pragmatic and practical job’ and those who are keen to rush early into complex things (including the still implementation unproven CDA) will collide with unknown consequences for all involved.

Whatever happens this looks to be a substantial management challenge for NEHTA and DoHA as the PCEHR will not go very far without the active support of the Standards Community.

I wonder just how much of all this has reached Senator Boyce’s ears?

David.

17 comments:

Grahame Grieve said...

You claim:

"Apparently at issue now is that if Standards Australia does not agree to much more NEHTA control of the Standards development process that the current agreement between DoHA and Standards Australia for funding of the work will not be renewed - with some threat to the jobs of the staff who are presently doing this work"

This is a grave claim. While it's obvious that there continues to be stress over timelines between standards and implementers (as ever), the claim that the funding for Standards Australia will be cut off and jobs are threatened is a serious accusation. You need to provide evidence to support this, or withdraw the claim.

Note that I post this in my own name, and not anonymously. I am a member of several IT-14 subcommittees, and contract to NEHTA some of the time, but I am not a memder of IT-14 itself, nor do I (or can I) speak on behalf of NEHTA, as I have clarified before here.

Thanks for the recognition to my blog post, btw. I'd like to claim the idea of leveraging our existing infrastructure as my own, but many people have thought of it.

Anonymous said...

You said:

1. “The feeling seems to be that the traditional methods of volunteers working to develop Standards is simply too slow and inefficient and that NEHTA needs to take over the process and drive it forward more rapidly and in a more focussed way.”

2. … “the current agreement between DoHA and Standards Australia for funding of the work will not be renewed …”

3. “Many of the volunteers are said to be concerned that ………. “

Now, as I read what you wrote there are:
(a) volunteers developing standards
and /or
(b) an organisation, Standards Australia, being paid to develop standards but using volunteers to do the work !

So would you please clarify precisely which it is? (a) or (b) or both .

Would you please clarify:
- How much is being paid to Standards Australia
- What the money is for
- Whether Standards Australia is paying for the work to be done and if not – why not.

Or am I to read it that Standards Australia is being paid to develop standards with the work being done by volunteers? If that is the case it is totally unacceptable.

At this stage in the game, given the importance of ‘Standards’ and the humongous amount of money Ms Roxon is throwing at e-Health, those people who are qualified to develop the standards should all be paid and paid at full commercial rates. They should not be expected to do the work on a voluntary basis under any circumstances.

This is what should have happened 5 years ago. The argument was put to that end 5 years ago. It remains the same today.

There is no place, none whatsoever, now or at any time in the foreseeable future, for NEHTA to be given control over the development of standards.

The only thing that needs to be done is to pay experts to work under the umbrella of Standards Australia to develop the standards required for e-Health as quickly as possible.

And to ensure that is clearly understood and agreed at the highest level Minister Roxon should sign a Declaration of Understanding to that end immediately.

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

Easy. Standards Australia is paid to manage and co-ordinate and provide support etc.

Volunteers have expenses etc reimbursed. It happens with all the huge number of SA working groups.

DoHA assists a little more with e-Health to make the material free - most Standards you have to buy.

World experience suggests paying experts is not as good as you might think in terms of outcomes.

David.

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

Hi Grahame,

I believe what I have written is pretty close to the mark based on conversations with a number of people who are on various IT-14 committees.

I have been careful to say 'apparently' and so on and if there is conclusive evidence I have got it wrong..like the SA/DoHA contract being suddenly signed then I am happy to post that information.

Right now a number of IT-14 members are not happy with the way DoHA and NEHTA are trying to pressure SA - and that is an indisputable fact.

I don't plan to withdraw my remarks - which remember are commentary reporting what I have been told by people I respect - until I am proven wrong.

I am not sure why commentary here would attract any concern. Those in the know will assess what I say on the basis of what they know and read, or not read the blog, on that basis.

Those who read and disagree are more than free to correct me if I have things wrong!

David.

Anonymous said...

Protections for anonymous speech are vital to democratic discourse. Allowing dissenters to shield their identities frees them to express critical, minority views . . . Anonymity is a shield from the tyranny of the majority. . . . It thus exemplifies the purpose behind the Bill of Rights, and of the First Amendment in particular: to protect unpopular individuals from retaliation . . . at the hand of an intolerant society.

http://www.eff.org/issues/anonymity

Now if only Australia actually had a Bill of Rights!

Anonymous said...

Good standards come from implementation experience and not the white board of the ivory towers that have been created. What seems like a good idea can flop badly in practice, while what seems clunky at first viewing can work well in practice. At least organisations like Google are brave enough to trash ideas that have not worked. Google health is one of those ideas.

It is true that Standards Australia have been pressured to fast track standards authored by Nehta. Fast tracking a standard that has not been implemented and has been authored by people without a reputation for workable specifications is a really bad idea. The cost of unworkable standards is enormous and no matter how glossy the brochure is, an unworkable standard is a monster that goes around consuming resources and then dies anyway.

It is vitally important that any new standard is subject to community review and trial implementations. It is false economy to do anything else. What many people do not realise that Nehta not only wastes taxpayers money, but consumes the limited bandwidth or implementors who normally do real work. Bad standards are very expensive because of this, which is why we have a standards process in the first place. "Fast tracking" them violates the safety mechanisms that have worked in the past.

When Doha and Nehta try an quash the critics you know we are in a dangerous place. It seems they are running the "Shock and Awe" eHealth plan, we know how well that methodology worked in Iraq.

Andrew McIntyre said...

I think its vital to allow scrutiny of proposed standards by the community and its wrong to fast track new standards, especially when they have not been implemented. OMG has pushed the need for implementations before something even becomes a standard.

The issue in Australia has been a lack of participation in the standards process by implementers. The reason for this is that we have had no governance to insist on standards compliance, so the standards are not important to Vendors. Simply enforcing standards compliance would change this lack of interest overnight. I find it amazing that my window has to have a Standards Australia tick to say it meets standards but patient histories and critical result data can be messaged in woefully defective messages, in complete violation to Australian Standards, without the regulators batting an eyelid. We don't need new standards to fix the problems, we need an expectation of compliance with the current ones as the first step.

Anonymous said...

"We don't need new standards to fix the problems, we need an expectation of compliance with the current ones as the first step."

But if that were true, then there would be no rational for NEHTA as it currently stands would there? In a parallel universe, NEHTA would have in its first 2 years selected the tranche of existing standards we could be getting on with, got Standard's Australia's support with no particular rush, It could then then slowly have upgraded the standards as required by experience on the ground.

But, in our universe, NEHTA believes it is being paid to create standards (whether we need them or not), and that they are the smartest guys in the room.

We really needed the NEHTA of that parallel universe, but what we got was an unaccountable private ivory tower. Then we got DOHA realising things were off track, but without the skills to know what to do, which triggered generous consultancies to the big private firms (who always look like they know what they are talkign about, and sometimes do).

I dont envy those that are no doubt now being asked to clean this mess up from within. But let me tell you, the train if off the tracks and it is running at full speed. Remember to pick your moment to jump off the carriages carefully.

Grahame Grieve said...

#Andrew

"I think its vital to allow scrutiny of proposed standards by the community and its wrong to fast track new standards, especially when they have not been implemented."

So when the minister says that there shall be a pcEHR by 1 July 2012, and it shall be based on standards, what do you propose to say? Don't use standards?

Andrew McIntyre said...

#Graham

I think that sometimes you have to say that "this is a bad idea", even if its not what people want to hear. The minister needs advisors that do not stand behind her and automatically nod their head. Advice does not have to be positive.

Anonymous said...

As I read this merry go round I see the same old bomb throwers at it again...

"you must use standards"

but!!!

"you must implement to before making it a standard"

but then when you try and implement anything if it's not already a standard then you can do it.

For engineers I think you all turn off your logic flags when you post on these blogs.

Maybe an attempt at a pragmatic way forward vs. this stereotyping garbage that goes on may actually help in a productive way.

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

I have always liked the approach of using the concept of a "Draft Standard for Trial Use" for a known period than then a move to a real Standard.

What do others think?

David.

Anonymous said...

Something similar along those lines such as:

"Draft standard for trial or controlled use"

Trial is too restrictive IMO. With necessary controls you can use things in a controlled way. Would require some guidance etc.

Andrew McIntyre said...

I don't think the logic flags are off at all, Standards should be based on something that is already working. Other vendors do their job by ensuring it does not advantage anyone to much, but are keener to implement when they see that it actually works.

HL7 V2 extensions are often developed by someone and brought to the committee as a solution to a known problem. Its a matter of having a strong implementation focus, rather than a whiteboard focus.

Anonymous said...

Question:

"So when the minister says that there shall be a pcEHR by 1 July 2012, and it shall be based on standards, what do you propose to say?"

Answer:

"The King is wearing no clothes."

Anonymous said...

Perhaps while the King has no clothes on, and the Minister is declaring that there shall be a PCEHR by 1 July 2012, others will be getting on with developing PCEHR specifications that are based on Australian and/or international standards whereever they are available (even in draft) and suitable for the purpose. And where they are not available, then the new specifications may themselves become candidates for new Australian Standards, or enhancements to existing standards. Isn't this how it works now? No vendor (or vendor client) who is serious about developing/implementing a system in a tight deadline waits for a standard to be developed and rubber stamped. Vendors will participate in the standards development process to make sure that they can influence the standard to suit themselves, and to make sure that their systems are designed and built in accordance with draft standards (so they can comply with tender requirements). Meanwhile, back at the vendor ranch, vendors are being pragmatic, and making sure that their systems are as designed to be as flexible as possible to meet current and future clients' needs. We all know that standards are important, but so is innovation (like the PCEHR), and like yin and yang - balance is important.

Anonymous said...

I don't think $467M with a short time frame is a sensible way to do innovation. The government could encourage innovation on the PCEHR program for a few million.

To innovate and force through standards as a concurrent exersize is a crazy strategy as the two things are fighting against each other. To do it with 9 sites at the same time is lunacy.

It comes down to sensible spending of Tax payers money and this is worse than cash for clunkers or Pink Bats. If the government is going to invest it should do so with proven standards and not a flight of fancy with the "Standards North Korea" model of standards development.

I can only assume that the people running this have no experience in standards development or software engineering. They have chosen the worst pieces of every past strategy and rolled them into one "Shock and Awe" strategy. There is no plan B and they have worked hard to cut off the oxygen from anyone else in the eHealth field.

I suspect many vendors are pretending to be interested for political reasons but doing as little as possible, unless they get bank rolled. I am amazed that the Gillard Government wants to take this amount of risk with another failing initiative, but its seems they are like the addicted gambler running out of chips. They are betting the ranch on high risk bets as they have nothing left to loose. It's hardly the way to run an eHealth program however.