Sunday, October 14, 2012

Has The NEHRS / PCEHR Initiative Reached A Tipping Point And Is It Now Heading Towards Oblivion? I Wonder.

I have been wondering just what is happening to the NEHRS / PCEHR Initiative as time from launch reaches well over 4 months and still use and adoption is seemingly rather stuck at very low levels.
A few things that have caught my eye:
1. A Google News Search for PCEHR finds a lot of coverage from Pulse + IT magazine, a few tech magazine mentions, and just one article in the mainstream media in the last month or so.
2. No press releases from DoHA on the e-Health project for a good while (months) other than peripheral initiatives.
3. NEHTA having not really updated their sectoral implementation plans for as long as anyone can remember.
See here:
The IHI Service plans have not been update in years and the last Vendor Webinar seems to have been at the end of July.
4. As of my check today there is not a single provider that is compliant with all the new ePIP requirements. (MD and ZedMed are going well however). Interestingly there have been no additional registrations in the last week or so after an initial rush.
5. NEHTA having a major reduction in funding,  skills and capability with the loss of many contractors who were working on a range on NEHRS related matters (If Government was serious in pushing ahead this would not have happened).
6. The Health Minister focussing on “training more doctors and dental reform” See:
7. Very little material in the medical professional press on e-Health (other than concerns about ePIP) - save a recent video I spotted in Medical Observer:

IN CONVERSATION

With e-health records set to become a significant part of general practice, Byron Kaye speaks with National E-Health Transition Authority clinical lead Dr Mukesh Haikerwal to clarify some GP concerns.
Specific link:
http://bcove.me/79ef6gix (seems to be fully accessible)
It is interesting that Dr Haikerwal’s main point was that the PCEHR was another tool for Healthcare Providers rather than for patients and did not replace what was presently happening with records and procedures.
8. The AMA saying (10 October release) on e-health the following.

“E-health

One of the biggest reforms currently in train that has the potential to improve patient health outcomes and experiences is in the area of technology and e-health.  As you would be aware, the AMA has been a vocal critic of many of the components of the Personally Controlled Electronic Health Record (PCEHR) in its current form.  While the AMA considers that the PCEHR has the potential over the long term to assist with pathways and improve coordination of care, the PCEHR itself also has significant limitations built into its design (e.g. opt-in and the patient’s ability to control what information is on the record).  This will limit its effectiveness and the potential benefits to patients and the downstream benefits for the health care system.  When clinicians do not trust the content of the e-health records, they will not use them and all the potential that could have been gained from a well-developed system will be lost.  
E-health is one of the key areas where linkages between the primary and acute care sectors can be made.  The AMA considers that any National Primary Health Care Strategic Framework must address in detail what needs to happen to ensure that the PCEHR and any other e-health initiatives are supported by GPs and general practices and well integrated into primary care.  The simple fact is that if GPs and their practices do not support the government-funded e-health initiatives, they will not work and all of that potential gain of linking primary health care with other parts of the health system will be deficient and a waste of health resources.”
The full release is here:
They are still by no means happy campers.
9. The quite impractical deadlines and for Vendors and GPs to reach ePIP compliance. (sure to shift I reckon.)
10. The reduction in coverage of the NEHRS / PCEHR from the NEHTA sponsored or paid entities.
11. The complete lack of any apparent public awareness campaigns etc.
Overall it seems to me this has been placed on the distant backburner at the very least and has had the plug pulled in all but name more than likely. (I await the announcement of the new “e-Health Change Management Strategy).
What do insiders really think is presently going on. A pause that refreshes, a major longer pause or a major wind-down?
David.

20 comments:

Anonymous said...

IMHO..
All the insiders are getting the bullet, anyone with any real ability would be going or gone.

NASH is stuffed, the PCEHR is devoid of any real clinical content and an embarrassment on all levels, cost, useability, local industry buyin.

State governments have changed and are in no mood to waste taxpayers money on what has been a manifest failure for local business and a boon for large generic multinational consulting firms.

Why would they be screaming about it from the rooftops? I think that we'll see this ivory tower quietly crumble over time.




Anonymous said...

Firstly , 10/14/2012 06:33:00 PM summarizes the essentials perfectly.

Secondly, David, I have to disagree totally with your comment that .... If Government was serious in pushing ahead this would not have happened.

The facts of the matter I believe are:
[a] Government is serious about ehealth and pushing ahead.

[b] Government has finally realised it has made a monumentally costly error of judgement by backing NEHTA and its smooth talking claim merchants for so long.

[c] Government knows it must find a way to extract itself from this mess fast and support a few less ambitious initiatives which involve private sector software developers who are positioned to deliver runs on the board immediately.

[d] The approach to [c] must be capable of strengthening Minister Plibersek's position as someone who can and does deliver positive outcomes in eHealth.

[e] These positive outcomes must be so good as to smother any bad news fallout arising from the demolition of NEHTA which must be well timed and swiftly executed.

[f] There will be some pain but that will be inevitable. Abbot as Health Minister in the Howard Government carries a fair proportion of the blame. The only constancy in this whole sorry mess is the Departmental Secretary.


Dr David More MB PhD FACHI said...

So what you are saying is the Government wants to push ahead with something - just sure it is not with NEHTA but with something else...

David.

Anonymous said...

Dear 10/15/2012 11:30:00 AM

You missed one point, a point which says to me government has yet to truly realise what it did wrong, and are not yet back on a path likely to succeed.

Very many senior folks in the Australian health informatics community have been saying that this current strategy is the wrong direction for a long time, in as constructive a voice as they can.

Their reward has been to be sidelined. If you have criticisms you are effectively expelled from the game, because you are 'anti e-health'.

Why are they not now being actively re-engaged with? They knew something then, they know something now. They actually want e-healht to succeed. Until that happens, the same big mistakes will be made.

Industry can not fix this policy mess on its own.

Dr David More MB PhD FACHI said...

You missed one point, a point which says to me government has yet to truly realise what it did wrong, and are not yet back on a path likely to succeed.

"Very many senior folks in the Australian health informatics community have been saying that this current strategy is the wrong direction for a long time, in as constructive a voice as they can.

Their reward has been to be sidelined. If you have criticisms you are effectively expelled from the game, because you are 'anti e-health'."

Seriously well said - especially the comment about labeling people 'anti-eHealth' simply because they disagree with the approach being adopted. All those who keep doing this know just who they are and the rest of us are taking names!

David.

Anonymous said...

David said: 10/15/2012 11:37:00 AM So what you are saying is the Government wants to push ahead with something - just sure it is not with NEHTA but with something else...

That is exactly what I am saying. Put another way Government knows the future of an efficient, effective, affordable health care system is very dependent on eHealth which underpins health reform. Government's problem is it knows the way it went about it has not worked - was the wrong approach - it just hasn't quite worked out how to extract itself out of this mess and embrace another approach when it can't quite work out what that other approach should be.

This is a most dangerous time for Government because all the fast talking high profile consulting firms will be polishing their speel to secure a big consulting contract to show Government how to do IT - and so the wheel turns one more time.

There is however the slim possibility Government may not be seduced so easily by the big firms who historically have been the involved one way or another in most of the major healthIT disasters in Australia. There is just the slimmest of possibilities an intelligent Minister like Plibersek might, as a first step, hunt down a few of the lesser known experts to hear their views before doing anything else.

Anonymous said...

To whom it may concern,

There needs to be a new mindset of receiving, evaluating and engaging with honest critical comment in the constructive vein it is given, rather than ignoring it. The approach to discovering real needs and independent research, with solutions around larger numbers of smaller, agile projects rewarded for achieving outcomes,not pick a winner and hold your breath. This will produce more success than a one size fits all punt that has wasted all the resources at hand in one bet.

I hope it is clear by now that large generic slow moving multinational consulting groups are part of the problem here. We do not need large predefined solutions thought up by consulting companies and the leaders that have ignored local stakeholders such as patient advocacy, professional, standards and local industry bodies. The outcome needs to be a clinical one that is real and verifiable not thought up and worked up as a career stepping stone.

I think we need the local stakeholders that work in the e-health industry to work on this because:
. Our health standards bodies are subscribed by all and accessible to all local players.
. They don't do anything else and they do appreciate the real issues and what CAN be achieved.
. They have some of the best knowledge and the best minds in the field.
. They have too much integrity to pass off an ordinary document management system that adds no clinical value at a huge price of over a hundred million dollars.
. They need to hold their heads up amongst their colleagues as decent creators of real benefits.
. They won't get experts to fly in from overseas, pontificate and piss off never to be seen again!
. They will make it work because they need to survive here in the ehealth industry.
. They don't use low paid overseas labor to produce the wrong thing for $1m a day Andrew.
. They discuss issues not change requests.


Hopefully the new approach, if there is one, will be much more inclusive of all industry stakeholders.

Anonymous said...

Tell 'im 'e's dreamin!

Bernard Robertson-Dunn said...

In 2007 Lynelle Briggs, the then Australian Public Service Commissioner released a document "Tackling wicked problems : A public policy perspective" which is available here: http://www.apsc.gov.au/publications-and-media/archive/publications-archive/tackling-wicked-problems and as a download

The conclusion of this document says: "Many of the most pressing policy challenges for the APS involve tackling wicked problems. Wicked problems are characterised by social complexity—they cross the boundaries of APS agencies, they cross jurisdictional boundaries, stakeholders (and experts) often disagree about the exact nature and causes of the problems and, not surprisingly, they disagree about the best way to tackle them. A key part of the solution to many wicked problems involves achieving sustained behavioural change. It has become increasingly clear that a disengaged and passive public can be a key barrier, and is a factor in the policy failures around some of Australia’s longstanding wicked problems. In the areas of welfare, health, crime, employment, education and the environment, significant progress requires the active involvement and cooperation of citizens."

IMHO the way that DOHA has gone about tackling eHealth has completely disregarded the advice in this document.

I haven't seen much in the way of "active involvement and cooperation of citizens" in eHealth. All I have seen is the usual big bang IT solution - the same approach behind most of the failed IT projects that happen every year.

It is not as though DOHA was unaware of the concept of Wicked Problems, I told them in my submission on the Draft ConOp. I also copied Lynelle Briggs, who by then was at Medicare. She replied, thanking me for my views and said she had passed my letter to her staff.

Lynelle's document and the advice of many commentators has been well and truly disregarded.

Is anything going to change? IMHO, not until the senior people in DOHA change. That is going to take years a) for the current lot to change their attitude or b) for the next lot to come along. Unfortunately, there is no guarantee that the next lot will be any better.

As Benjamin Franklin said "The definition of insanity is doing the same thing over and over and expecting different results". Large scale government IT projects keep failing for the same insane reasons.

Anonymous said...

Peter Fleming has publically stated "eHealth is not a wicked problem".

Is it any wonder NEHTA is caught perpetually holding the wrong end of the stick and picking up the pineapple the wrong way around?

While these inmates continue to run the asylum, eHealth is a long lost and long suffering cause!

And DOHA’s recent anatomy poster is “proof positive” these self-serving bureaucrats truly don’t know the difference between their elbows and their a-holes.

Anonymous said...

" a boon for large generic multinational consulting firms."...
"because all the fast talking high profile consulting firms will be polishing their speel "..."seduced so easily by the big firms"

These 'firms' (Management Organisations) don't need merit. They will merely fund the political parties (another Management Organisation) with election campaigns and lobbyists that reward them with these 'infrastructure' projects (IT and non-IT).

I think you David and the most of the commentators are really ignorant or too myopic to the issue of corruption that it really is. You are deluded to think you can reform or change this based on some logical or professional arguments.

Dr David More MB PhD FACHI said...

"I think you David and the most of the commentators are really ignorant or too myopic to the issue of corruption that it really is. You are deluded to think you can reform or change this based on some logical or professional arguments."

That is a pretty big call. If you have any real evidence - other than an impression of some sustained 'snout in the trough' behaviour you know who to call - the Police!

My experience having used and being in a big 5 consulting firm it that occasional over servicing yes, using your watch to tell you the time yes, lack of real industry expertise yes - deliberate corruption no.

David.

Anonymous said...

As the commentator 10/16/2012 07:39:00 AM has so rightly observed - I think you David and the most of the commentators are really ignorant or too myopic to the issue of corruption that it really is. You are deluded to think you can reform or change this based on some logical or professional arguments.

Therefore, difficult though it might be to overcome such corrupt practices some laser sharp strategic thinking and tactics will need to be defined and deployed. Where are those thinkers and how do we enroll them to help our cause.

Anonymous said...

Here is a thought. If you are annoyed at this.

The first place to start is a targeted campaign to the Federal Minister. We should send faxes to the Minister's office asking:

When is DOHA going to start supporting local e health small business and its workers?
What economic benefits accrue to Australians for the 100 million plus spend on the empty PCEHR?
Why we built a lemon, with no clinical content, against all the advice of local health informatics experts?
Why local health companies have received NONE of the PCEHR work when overseas large generic consultants were given so much?

The same fax should be sent to the local state ministers, who after all have invested half the money here and their local constituent businesses have received short shrift from DOHA and Nehta. A billboard asking the same question might get a bit of attention from the minister.

Remember the last thing they want right now is to have the light shining on the none delivery of the NASH and the mundane rubbish put up for the PCEHR. A manifest waste of more money than they are taking away from other needy social programs. So my advice is get the spotlights out!! Shout it from the rooftops until they change the behaviour.

What we really need is a fighting fund to launch an effective lobbying campaign in the minister's electorate on behalf of the medical software industry. Otherwise the federal bureaucrats will simply laugh at the industry and give them the finger. I know its not all her fault but unless we get this bad behavior noted then we won't get any sort of change.

As some commentator has indicated

"the fast talking high profile consulting firms will be polishing their speel to secure a big consulting contract to show Government how to do IT - and so the wheel turns one more time".

Watch and weep!

Anonymous said...

"When is DOHA going to start supporting local e health small business and its workers"

You know, if the local healthcare software industry is going to run a campaign, it should at least be a little sophisticated.

DOHA is accountable to taxpayers, and I'm sure they would think that supporting local e-health small business is a priority for them.

right....

Bernard Robertson-Dunn said...

Anon said:

Peter Fleming has publically stated "eHealth is not a wicked problem".

I'd be interested to know where he made this statement.

He is quoted on this blog :

During the Health Infomatics Conference in Brisbane, earlier this month, Mr Fleming described the establishment of the eHealth system as a massive “challenge”. But, he said, once overcome, it will significantly change the world in which we live and make a huge difference to the health care system of the future.

Any solution that changes the world, by definition is a wicked problem.

IMHO, no solution will be successful if you don't understand the problem.

Anonymous said...

wrong ... most of them have almost bee driven to the wall. Gov't only wants to deal with large corporations with health balance sheets.

Anonymous said...

Bernard Robertson-Dunn said... Any solution that changes the world, by definition is a wicked problem.

Bernard, I respectfully disagree with your assertion here, and we only need refer to the seminal Rittel/Webber paper “Dilemmas in a General Theory of Planning” (1973) defining the nature of “Wicked Problems” to illustrate the error of your assertion.

ABSTRACT:
The search for scientific bases for confronting problems of social policy is bound to fail, because of the nature of these problems. They are "wicked" problems, whereas science has developed to deal with "tame" problems. Policy problems cannot be definitively described. Moreover, in a pluralistic society there is nothing like the undisputable public good; there is no objective definition of equity; policies that respond to social problems cannot be meaningfully correct or false; and it makes no sense to talk about "optimal solutions" to social problems unless severe qualifications are imposed first. Even worse, there are no "solutions" in the sense of definitive and objective answers.


The essential characteristics of Wicked Problems are defined as such:

1. There is no definitive formulation of a wicked problem
2. Wicked problems have no stopping rule
3. Solutions to wicked problems are not true-or-false, but good-or-bad
4. There is no immediate and no ultimate test of a solution to a wicked problem
5. Every solution to a wicked problem is a "one-shot operation"; because there is no opportunity to learn by trial-and-error, every attempt counts significantly
6. Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan
7. Every wicked problem is essentially unique
8. Every wicked problem can be considered to be a symptom of another problem
9. The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem's resolution
10. The planner has no right to be wrong

”We are thus led to conclude that the problems that planners must deal with are wicked and incorrigible ones, for they defy efforts to delineate their boundaries and to identify their causes, and thus to expose their problematic nature. The planner who works with open systems is caught up in the ambiguity of their causal webs. Moreover, his would-be solutions are confounded by a still further set of dilemmas posed by the growing pluralism of the contemporary publics, whose valuations of his proposals are judged against an array of different and contradicting scales.”

”… it should be clear that the expert is also the player in a political game, seeking to promote his private vision of goodness over others'. Planning is a component of politics. There is no escaping that truism.”

So we see here that “changing the world” has nothing to do with Wicked Problems, as if that was the case, Radio, Television and the Internet would all then be deemed wicked problems and they are most definitely not, nor are there “definitive and objective answers” for solutions to “wicked” problems. Healthcare, Education, Welfare, Crime and most targets of “Public Policy” are most definitely “wicked” problems, and as a result, Bureaucrats in their “Fatal Conceit” tend to make a demonstrable meal of their plans and feeble attempts to solve and tackle “wicked problems”! PCEHR, an obvious case in point.

E-Health, inextricably caught-up inside the tangled web of our socialised healthcare system, is most definitely a “wicked” problem, and arguably ticks all 10 boxes for the characteristics of wicked problems as stated above, much to the disappointment and misguidedness of Mr Fleming and his Executive Team.

RECOMMENDED READING: Dilemmas in a General Theory of Planning, Policy Sciences , No. 4, 1973, pp.155-169

Anonymous said...

David More said:
"That is a pretty big call. If you have any real evidence - other than an impression of some sustained 'snout in the trough' behaviour you know who to call - the Police!"

An example might just be: "IT service found 'corrupt'"


Where there's smoke there's fire, and this example lends itself to DOHA/NEHTA funding allocation behaviour of a questionable record throughout the PCEHR mad millions/billion splash!

Yes please, someone should call the Police and have an Ombudsman/Auditor investigate if what DOHA/NEHTA are doing and have done with taxpayers money is truly legitimate?

Bernard Robertson-Dunn said...

Anon said:

"Bernard, I respectfully disagree with your assertion here ....."

I'm not sure what you are disagreeing with.

Your statement 'So we see here that “changing the world” has nothing to do with Wicked Problems, as if that was the case, Radio, Television and the Internet would all then be deemed wicked problems and they are most definitely not ...' is invalid.

I agree that Radio, Television and the internet are not wicked problems - they are solutions. However, these solutions changed the world and so changed the original problems.

In the rest of your posting we appear to be in complete agreement. I even used the "Dilemmas in a General Theory of Planning" reference in my IBM Journal of Research and Development paper - Beyond the
Zachman framework: Problem-oriented
system architecture.