Tuesday, August 27, 2013

The Coalition Is Planning A PCEHR Review - What Should We See From The Review.

As I mentioned last week we found this late in the week from Coalition Policy.
In the full .pdf of the policy a review of the PCEHR is mentioned.
Page 15:
"Health professionals will be increasingly reliant on effective e-health tools to better
coordinate care, particularly for patients with complex health conditions.  Unfortunately, the Labor Government has failed to deliver on its Personally Controlled Electronic Health Record (PCEHR).
Despite the $1 billion price tag, only 4,000 records are reported to be in existence. In recent weeks, the clinical advisers for Labor's e-health record program have quit  en masse, leaving the Federal Government's flagship programme floundering with virtually no clinical oversight.
If elected, the Coalition will undertake a comprehensive assessment of the true status of the PCEHR implementation. In government, the Coalition implemented successful incentives to computerise general practice and will continue to provide strong in principle support for a shared electronic health record for patients. The Coalition will again work with health professions and industry to prioritise implementation following a full assessment of the current situation."
 Here is the link.
For me the review has to address the following.
First we need to know just where the implementation of the PCEHR is actually up to and just what levels of usage it is seeing - separate from the spin being put out by DoHA. We also need to understand where all the money has gone, who has profited and if there has been any issues like have been seen with the Qld Health payroll procurement and implementation.
Second we need a serious evidence based review of the options for having what has been built actually be used better and to have it actually achieve the desired health and clinical - and not technical outcomes. My feeling if this is done it will be concluded that the design of PCEHR is fatally flawed from both a clinical and patient utility point of view and needs a pretty large scale re-design. The opportunity cost of not correcting course and starting to invest in approaches that are more likely to work and deliver the Health Sector benefits we need is huge I believe.
Third - with a clear idea of what might work and where our gaps are - we need to plan how we migrate from where we are to where we need to be. The plan needs to be stakeholder and benefits focussed.
Lastly we really need to come up with an approach to the leadership and governance of the e-Health domain that much better manages the power of government, vendor needs for profit and opportunity, consumer requirements and the clinician’s need for quality and safe Health-IT. We need to properly balance all these interests while ensuring proper accountability on the part of each stakeholder.
A Clayton’s review is really not an option as all that will result in is good money being thrown after bad. Of course, the review needs to be made fully public
Remember e-Health is not intrinsically a good. To make a difference it has to be done well with co-operation and commitment from all.
David.

13 comments:

Bernard Robertson-Dunn said...

David,

You say in your commentary "... we need to plan how we migrate from where we are to where we need to be".

I have a couple of observations about that statement.

1) Nobody has defined "where we need to be" in sufficient detail. There are a lot of motherhood statements about using IT to deliver eHealth, about easier access to health information and about personally controlled health records. What is missing is a more complete and comprehensive description of "where we need to be" that can communicated to stakeholders and be measured in terms of health outcomes.

2) Achieving a goal of improved health outcomes enabled by the use of modern information systems requires more than planning. If you fully understand the problem and your solution options, then planning, i.e. scheduling tasks and resources might work. When you haven't defined your problem and are working in an environment of major changes to the way people work, it takes more than just planning, it takes innovation, vision, leadership and persuasion. And as I've said before, an information system is a tool, what matters is how it's used.

Tony Abbott's statement doesn't fill me with hope:

"If elected, the Coalition will undertake a comprehensive assessment of the true status of the PCEHR implementation. ... The Coalition will again work with health professions and industry to prioritise implementation following a full assessment of the current situation"

Oh goodie. They will assess the status of the PCEHR implementation and then prioritise implementation.

What the heck does that mean?

For a moment let's pretend the PCEHR is a car. It stops working. It won't start reliably, when it does it lacks power and doesn't brake well. You call the NRMA. The service man gives the car a once over and says - "my assessment is that it's not working". That's a lot of help. So you get it towed to a service station for a second opinion. The report says "our assessment is that the engine has blown a gasket, the transmission is stuffed and the brakes are worn out. It will cost twice as much as the car is worth to repair."

So what do you do? Sell it for scrap and buy a replacement?

You head off to your local car dealer and ask them for advice. You tell them you have a Mazada 1 which is beyond repair and want to price a replacement. The dealer, being a good dealer ask the question "what do you want the car for?" Your reply leaves the dealer stunned. You need the car to tow your four berth caravan when on holiday and your two-horse float every weekend.

The reason your car has worn out is because you have the wrong car. The NRMA man and the service station couldn't tell you that because they only saw the car. You didn't tell them what you wanted it to do.

The issue is not the car, it's your choice of car.

Getting back to the PCEHR, it's the same situation. They can assess the PCEHR as much as they like, but without a description of what it is supposed to do - in terms of health outcomes, not registrations and health summaries - any assessment is useless. The only question it answers is "we must do something, what can we do?" Unfortunately, doing something is not the same as doing something useful.

Anonymous said...

Bernard, you are in the wrong job!!

How you could have save us all a billion dollars - I only hope someone points Tony Abbott in your direction as you have nailed it on the head really when it comes to the PCEHR.

Anonymous said...

Yes - who will the government (whoever it is) choose to do the comprehensive assessment of the true status of the PCEHR? Is there a consulting company left that has not already had its snout in the trough?

Dr Ian Colclough said...

Irrespective of which consulting company is selected to lead the review they will not have the requisite expertise on board to do the job. More often than not they rustle up their experts from among overseas partner organisations and therein lies the first major problem. Such experts are burdened with heavy luggage and dirty linen acquired from their overseas activities which gets infiltrated into the Australian scene.

The experts required are here in Australia. Selecting the right fit and expertise and engaging them together under the umbrella of the consulting company is the really hard part.

Anonymous said...

The problem with the expertise available here in Australia is that it's loaded with conflict of interest one way or another. But what kind of review are they logo king for...? I was thinking a parliamentary committee process: more about the politics than the system.

Anonymous said...

There will be some conflict of interest regardless whether it be overseas or local experts - that has to be managed - and it can be.

Bernard Robertson-Dunn said...

Let's compare Health's approach to that of AGIMO and cloud computing.

If you believe the vendor world (and I don't) cloud computing can save IT departments huge amounts of money and can make them more responsive with respect to system demand for resources.

AGIMO (who is primarily interested in internal government IT systems, not Australia's IT industry) has recognised that there is more to cloud technology than the technology. It has been looking at issues of data sovereignty, risk and procurement issues.

There is a report in yesterday's media http://www.itnews.com.au/News/354837,feds-concerned-about-cloud-escape-route.aspx where John Sheridan of AGIMO said "while cloud computing could make it easier to set up and fund new systems, it could also back agencies into a difficult corner should their requirements change."

In his slide deck http://www.haikudeck.com/p/OBa1DcwcnL/the-accordion-effect# he covers topics such as :
Consumerisation vs Security
Cloud vs Privacy
Opex vs CapEx
Propriety vs Open
Alone vs Friends
Social media vs Control

In other words, AGIMO is exploring the issues surrounding the use of the technology, not the technology itself.

Health could learn a lot from AGIMO.

Someone in Health had what seems to be a good idea - use IT to better manage health information. Instead of "thinking it through" they asked for a huge amount of money and spent it, (IMHO) most unwisely.

One of my observations is that any solution will create new problems. AGIMO is thinking through problems that adopting cloud computing is likely to create. Good for them.

Health has just created much greater problems than they started with, mostly around politics and saving face. If any review of the PCEHR is limited to its implementation, then they are looking in the wrong place. It is quite possible that they are looking in the wrong place because they can blame someone else.

IMHO, the root cause lies in Health's initial decision to implement the PCEHR without thinking it through. It is unlikely that that decision will get reviewed. I hope I'm wrong.

Anonymous said...

"IMHO, the root cause lies in Health's initial decision to implement the PCEHR without thinking it through. It is unlikely that that decision will get reviewed. I hope I'm wrong."

Unfortunately Bernard, you may be wrong but for another entirely different reason.

The Root Cause doesn't necessarily exist in the Wicked Problem sense, as you have well demonstrated and articulated many times yourself.

There are many countless forces and failings that have resulted in the present less than desirable outcomes we have with the PCEHR and its monstrous waste of Taxpayers’ funds!

You undoubtedly will not be surprised to hear of the presence of a core set of resources (Brains-trust) heavily psychologically, emotionally and professionally invested in the vision and dream of a PCEHR and what wonders and salvation it shall bring to the many ailing healthcare sectors' maladies. They are sprinkled throughout DOHA and NEHTA with gullible incompetent leadership indulging their worldview.

Tragically, this passion is founded on nothing but unadulterated misguided belief! Hence the conspicuous absence for any objective evidence to substantiate the energy and investment in the PCEHR and the active concealment of the Business Case from Public scrutiny...

Any evidence contrary to their beliefs is discounted and ignored much as a deluded addict will discount and avoid any "truths" conflicting with their own perverted and distorted worldview.

As a result, a single-minded drive to realise the PCEHR deluded wet-dream emerges with many vacuous clingers-on, unencumbered of any original critical thought, profiting from profligate Taxpayer funded waste without the slightest conscious thought of "thinking things through" to the detrimental results of their behaviour and adverse contributions to the underlying ongoing wicked problem.

If there is such a "root cause", and I highly doubt there is such a beast, no review or inquiry will have the capability, insight and stomach to surface its nature and hold those parties responsible and accountable for holding and enforcing their misguided "beliefs" at the negative expense of everyone else in the process.

A "witch hunt" truly is required, but as the recent QLD Health Payroll debacle and inquiry has demonstrated, it's NOT going to happen in anyone’s lifetime reading this.

Yesterday’s debate wrap-up zeroed in on the true protagonists of the Healthcare sectors vested perverted interests: Politicians, Bureaucrats, the AMA and the Pharmacy Guild!

While these stakeholders call the shots and govern the taxpayers' resources, rest assured resources allocated to front-line services for the benefit of Patients will not be the primary focus and end result…

Bernard Robertson-Dunn said...

Anon said "Unfortunately Bernard, you may be wrong but for another entirely different reason."

When I say I hope I'm wrong, I'm predicting that the review will not include the initial decision. Unfortunately, I think it's likely that I'll be correct.

Re the rest of your post, I have no knowledge of the individuals involved or their motivation. My comments are all based upon publicly available information and my experience and knowledge of other projects that share similar characteristics.

Anonymous said...

Bernard,

Think you may have skipped the bit RE: "...wrong but for an entirely different reason…"

Assertion still stands.

RE: The rest of your post...

You don't have to personally know the Accountant or the CFO to identify and recognise where Financial Fraud is being perpetrated!

If you have an issue with the "initial decision to implement the PCEHR", what exactly do you think is the issue?

"Thinking it through"?

Do you truly believe the "Decision Makers" have the capability and insight to "think things through", and if the same protagonists behind the original decision had a doover that a different outcome would result?

You don't need "insider information" to speculate and muse on the ongoing PCEHR madness and form an informed opinion on what and who's at fault for this Taxpayer funded healthcare debacle...

Anonymous said...

I think here is probably a good a start as any, considering the state of the systems concept of operations, standards and NeHTA's fragmented and low quality Archtecture
http://infowayconnects.infoway-inforoute.ca/blog/global-perspectives/907-national-electronic-health-record-perspectives-australia/

Anonymous said...

Looks like a statement from the Spin Doctors at NEHTA's media department!

Can't see any evidence of Architecture rigour or insight with these empty platitudes, which provides ample evidence for why we're in the eHealth mess we're in.

Let the Witch-hunt begin September 9, as with evidence and cookie-trails such as this provided here, it won't take very long to zero in and nail the culprits responsible for the exorbitant PCEHR waste of taxpayers' funds...

Anonymous said...

With the rest of them no longer at NeHTA at lest Peter Fleming still has one disappointment to hang before he is provided new opertuniies and is thanked for all his hard work