Friday, May 25, 2012

Here Is A Considered And Very Useful View Of the NEHRS (PCEHR) And Its Problems.

I came across this in Pulse+IT a few days ago and Emma Hossack (the author) has told me she is happy if I re-publish her ideas here on this blog.
Over to Emma.

MSIA: The eHealth paradigm and the PCEHR

Written by Emma Hossack on 18 May 2012.
This article first appeared in the May 2012 edition of Pulse+IT Magazine.
The 2008 National eHealth Strategy set out a number of noble aims that were supported by industry and government alike. Industry confidence was at a high when then-Health Minister Nicola Roxon outlined her plans for a national eHealth system. Things have not progressed according to the plan, however, and there are a number of lessons that we can all learn to ensure this doesn’t happen again.
“A healthy population underpins strong economic growth and community prosperity. Australians therefore have a strong incentive to ensure that our health system is operating efficiently and effectively, and continues to deliver a high standard of care that aligns with both community and individual priorities[1]. One of the ways to realise this is through eHealth. The benefits of eHealth are clear[2] and Australia’s current health expenditure is not sustainable if it remains on the current trajectory[3]. Consultations and reports on the need for eHealth in Australia have been persistent and bipartisan since 1994 and many have been calling for an end to all the talk, and for eHealth to begin with more than unsustainable pilot programs.
So why is there so much controversy about the federal government’s $467 million spend on eHealth reform[5]? And just why is it so heavily focused upon the PCEHR? The implementation of any new national system is a huge challenge, and can expect to attract controversy. In the field of health it affects everyone — so opinions abound. At present there is politically fuelled criticism, concern about how well it will serve the Australian health consumer[6], and trepidation about whether the personally controlled electronic health record will be useful, privacy compliant, secure[7], safe[8] or efficient[9].
Probably of greatest concern of all is the theme which eschews all these as unnecessary worries — because, this line of thought goes, there is not any real likelihood that the PCEHR will be used once the pilot sites have achieved the various goals including Healthcare Identifier matching (an interesting imperative in itself).
Yet despite all of this debate, there is an overarching air of genuine optimism in the Medical Software Industry Association about the underlying rationale for the current investment, evincing as it does a clear recognition of the value of eHealth solutions working today, and the willingness of the government to invest in eHealth and reap the benefits of interoperability.
eHealth is a noble cause as health is the most significant barometer of a country’s success. It is also Byzantine in its complexity, which means it captivates a unique array of players, all sharing a desire to see eHealth benefits maximised. As one of the consumer stakeholders has aptly pointed out, eHealth, unlike banking and almost every other industry, is an arena where many systems must communicate seamlessly with many other disparate systems for it to work[10] in the multi-tiered, distributed eHealth space. This is not your average bunch of vendors.
At the April 2012 MSIA CEO Forum[11] one of the most persistent themes was the participants’ pride in the success of eHealth projects with which they were involved in with their clients, inside and outside the current government spending initiatives, and beneficence — the desire to promote the clinical benefits which resulted from the use of information — not simply the technical prowess of the software solutions[12]. Consequently, there is naturally disappointment when things have not gone to plan and a keen desire to help get things back on track[13]. It is in this context that some observations will be made on the comparison between what Australians will have on 1 July 2012, and more importantly, what was promised.
The path to success is rarely swift and straight as indicated by the recent Parliamentary Library paper ‘The ehealth revolution — easier said than done’[14] which provides a useful summary of Australia’s eHealth over the last decade.
The much lauded Deloitte eHealth strategy 2008 was supported both by the National Health and Hospital Reform Commission and the federal government. Apparently it still is — at least in speeches. It proposed that the eHealth reform should:
  • Be a 10-year journey.
  • Build on the success of existing eHealth solutions.
  • Not be prescriptive but focus on strong infrastructure and where possible robust international standards.
  • Be sustainable. Provide incentives for clinicians to take up the eHealth solutions.
  • Have a strong and transparent governance framework to ensure confidence of the industry, clinicians, consumer and governing bodies[15].
The NHHRC endorsed this. It went further in Recommendation 123, which stated that the government should not design, buy or implement eHealth systems. The government endorsed the report, which augured well for Australia. Minister Roxon added to the confidence felt by industry and stakeholders generally when in her launch of the eHealth “revolution” on 30 November 2010[16] she announced that $467m would be spent on “major infrastructure” for a PCEHR[17], and, significantly, she stated:
“We’re getting on to deliver the next steps which will result in empowering patients, linking vital information to make doctors and nurses lives easier. We’re doing this based on the hard work already achieved, not trying to build a one-size-fits-all system from scratch. Let me take you through some examples.”
Whereupon the minister described the first three “Wave” sites of Brisbane North, Melbourne East and Hunter Valley. GPpartners in particular was singled out as “an Australian leader in eHealth for many years”. The sites were tasked to deploy and test eHealth infrastructure and standards, provide evidence-based results, influence change management processes and inform the process for implementations elsewhere. The message on governance was strong: DoHA was to assume ultimate oversight of the project and NEHTA was its contractor to develop and to deliver infrastructure.
“We want the best available expertise and experience so there will be an open approach to the market for key elements of the program. I can confirm to you all that this Government is not looking to run the whole system. Our job is to contract partners to build the infrastructure and the linkages and to set the standards and regulations. It will not be our job to deliver all of the technological advances — that’s what we’re looking for from the innovators in industry.”[18]
In essence we were told that the reform would follow the Deloitte eHealth strategy. However, even on 30 November 2010 the first three Wave sites had been chosen and funded without an open tender process. Tragically for Australian taxpayers, there was no governance around how they would procure eHealth services or manage conflict of interest — be it to continue with existing suppliers following an open tender process, or instead resolve to make an internal selection and start building something new[19]. The appropriate governance emphasised by the minister, and later embedded in the PCEHR Concept of Operations, had been ignored and raised questions about the transparency of NEHTA as manager of the procurement process.
The industry and specifically providers of robust solutions should probably have banged their drums louder about this sleight of hand. This may have prevented unnecessary cost to the Australian taxpayer by trying to reinvent the wheel rather than using, extending and upgrading current systems.
For example, Ms Roxon was shown the HRX system in July 2010 by Dr Richard Kidd, director of GPpartners, just one month before she awarded funding for the Wave 1 sites. A press release[20] issued on the day of the visit stated:
Dr Kidd said he was grateful Ms Roxon had the opportunity to view the HRX first hand as it was necessary at this stage in the health reform process that the government was kept fully informed regarding the system’s extensive capabilities.
“GPpartners is confident that the HRX already provides an effective solution to some of the difficulties health providers face with regard to the sharing of patient medical information across multi-sector, multi-disciplinary care environments,” Dr Kidd said.
The speed of testing for the infrastructure could have been faster, and a more effective use of funds could be made on change management and not software development which the minister had specifically eschewed previously. Sadly, this was a wasted opportunity to get some solid and valuable results for the promotion of eHealth to Australians. It behoves the industry to ensure that in future the funding bodies are crystal clear on the facts relating to procurement of technology so that the taxpayer gets value for money. Fortunately the second Wave projects followed clear procurement guidelines and whilst there were only nine ‘winners’, the procurement methods were appropriate and there was no concern about probity.
The decision to put out tenders for GP clinical information systems was possibly limited. In the health market there and numerous GP desktop systems; some clearly have a market share and others provide more specific needs, such as those for indigenous health practices. As recognised by the RACGP and MSIA in 1995:
Standards in general practice information management contribute significantly to a better practitioner working environment [and] better or more accessible information pertaining to patients and their health problems. [Standards] will work to ensure that components will work appropriately, will work in concert with one another where appropriate, and will perform tasks according to a level of efficiency and reliability that is of assistance and utility to the general practitioner as an individual and the general practice community as a whole[21].
A standard application programming interface (API) requirement for all clinical systems would create immediate value for interoperability. Where these are not provided, there are serious risks that data will not be shared, or will be extracted or uploaded without both parties’ co-operation to ensure that changes and upgrades do not compromise the doctor’s record and thus patient safety where the data is used to inform decisions. The concerns relating to this practice are documented[22].
If instead of selecting a vendor panel, an invitation to apply had been released for the creation or enhancement of APIs for a myriad of other valuable applications, this could have resulted in Australia taking a huge leap ahead in both interoperability, and importantly, realisation of clinical benefits. As it stands, the duplication by many vendors of interfaces to the same system, usually paid for with government funds, create no value after the first interface has been developed — just waste and lack of conformity. Safety risks too, are avoidable. The danger to the market place should not be overlooked either — if your clinical system was not one of the ‘winners’ does that impact on prospective markets?
In the period after the Deloitte eHealth strategy, the NHHRC report and the Wave bids, the Shared Electronic Health Record concept seemed to undergo a metamorphosis into an IEHR, PCEHR and now a National Electronic Health Record System (NEHRS). This is not in line with the broader objectives of an eHealth paradigm or successful overseas experience. Indeed, it was not what the minister signed up for in her very specific 30 November 2010 speech. It can only be assumed that someone else with a Svengalian skill of transformation had quite a different vision, or simply wanted to transplant a system built for a different market and population into Australia.
This created a bewildering and unnecessarily complex national architecture suited specifically to large-one-size fits-all system. It also created quite a different and unexpected role for NEHTA which became deeply involved in the very activities which the NHHRC warned should not be in the government’s remit[23]. The PCEHR Concept of Operations extended some of the original goals beyond recognition and whilst recognising value in the federated conformant repository model[24], the clear mandate of the National Infrastructure Partner was to build a one-size-fits all system, or bring it from overseas, irrespective of well-documented evidence that nowhere else in the world had experienced success this way[25].
However, this work is not easy or necessarily useful, as we know from the UK experience, which had many of the same players. In 2005 the British Medical Journal printed a case study by Sheila Teasdale on the failed early implementation of Kaiser Permanente in Hawaii[26]. The report was written in the vain hope that the English National Programme for IT would learn from these mistakes; namely, to quote Professor Trisha Greenhalgh’s advice to government following her study of the failed UK exercise:
  • There is no ‘tipping point’ for big IT.
  • Don’t try to build systems or write standards.
  • Don’t throw money before you’ve sussed the complexity.
  • Don’t equate knowledge with what is passed up the line.
  • Don’t impose political milestones.
In Australia, now that the 10-year plan proposed by Deloitte has been compressed into 18 months, we have witnessed the inevitable pressure which has resulted in ‘pauses’[27] and questions being raised by a Senate inquiry[28]. Not surprisingly, there has also been a clear campaign to reduce public expectations to little more than a patient sign-in to an empty national database. The medical software industry has been providing healthcare solutions for decades, long before the current PCEHR program, and the HealthConnect one before that. There is no doubt that it will continue to do so. However, it is worth reflecting that if the government is going to spend on eHealth again in the future, it would be great if the medical software industry could be empowered to:
  • Build for real needs not political aspirations.
  • Use local development for local communities.
  • Listen to the healthcare providers, privacy practitioners and software industry to support what is working and build on that to get some concrete health improvements.
Starting the eHealth reform was a bold move and without doubt a well-intentioned one which should be commended. The plan was good, but not followed. The criticism has been public, but at least it has kicked off the requisite debate and public education. The industry remains optimistic that once the political imperatives are removed, the stakeholders’ desires for systems to be useful rather than useless, extensible not expedient and provided amidst a transparent framework, then greater focus can be given to the improved health outcomes possible with the many eHealth tools. Next time around we will surely be given the chance to get a lot more of it right — and from a lot less — and maybe even see some of the magic in it[29].

Author Details

Emma Hossack
B.A. (Hons) Melb, LLB (Melb), L.L.M
Committee member: MSIA
In addition to being a Medical Software Industry Association committee member, Emma has been CEO of Extensia for several years following her life as a corporate lawyer. Emma is currently vice president of the International Association of Privacy Professionals and is a regular speaker on privacy.

Competing Interests

Emma Hossack is CEO of Extensia, a medical software development company. One of Extensia’s principal products is RecordPoint, a shared electronic health record.
The full article (with references etc. ) is here:
I really have nothing to add - other than to point out that had the 2008 National E-Health Strategy actually been funded and implemented I suspect the rather dysfunctional mess we now have might have been avoided - at least to a large extent and we would not - at the same time - have done so much damage to the small Australian Health IT vendors.

1 comment:

David Rowed said...

"A standard application programming interface (API) requirement for all clinical systems would create immediate value for interoperability."
This is achievable through the standards process at HL7 International's Service Oriented Architecture (SOA) Working Group where a related proposal from the Australian members to specify the services and functional groupings thereof has been accepted in principle by that WG. This would allow modularisation and orchestration of functionality from different vendors and knowledge suppliers. As the overall argument put to SOA was around the point-of-care application(s) which should be delivered in accordance with the General Practice Computing System (GPCS) Functional Specifications ( project funded by DoHA, supported by RACGP, and led by our esteemed blogger, D.M. ), the work is to be initially focussed on Primary Care. To progress beyond the concept stage, we require support and work commitment from a few organisations prepared to do the heavy lifting. This is the only way forward for the next generation of systems.
The need for this is long-recognised by the Clinical Decision Support community who are always trying to work around these problems.and it is in their standards groups that work is taking place both at HL7 International and here in Standards Australia's recently-formed IT-014-013 Clinical Decision Support Working Group. Apart from CDS and SOA there is need for standards organisations and government funders to widen the traditional approaches and support these more bottom-up , deployment-leveraging approaches. Already openEHR, and Demographics functionality are available as services sets from some developers , and are suitable for deployment alongside other modules. CDS service interfaces have been specified by HL7/OMG, and Australia has taked a key role in the Human Services Directory HL7 standards and jurisdictional rollouts.