Wednesday, August 06, 2014

Article Draft : Australian E-Health Finds Itself At A Crossroads. It Is Hard To Know What Comes Next!

In the last few months there have been a number of releases and events that we will look back and see as having been quite seminal for the whole Health IT endeavour in Australia.
First we had the release of the Federal Budget on Tuesday May 13, 2014. This has been one of the most contentious Budgets in recent memory, especially regarding some aspects relating to health (e.g. the proposed $7 Medicare Co-Payment). As far as e-Health is concerned an additional 1 year of funding was provided to give Minister Dutton time to work out what to do with the whole eHealth / PCEHR program.
There is a detailed review of a range of the Budget measures undertaken by the Parliamentary Library and some commentary found here:
Second we had the release of the Royle review of the Personally Controlled Electronic Health Record (PCEHR) which was requested by Health Minister Dutton on taking office after the election. The PCEHR Review was handed to Government in December, 2013 (after having taken just 6-7 weeks) and released just after to the Budget in May 2014.
The full Review can be obtained from this link:
A summary of the recommendations from the 91 page Report are found on page 16 of the report and - in very broad terms can be summarised as recommending:
1. Much improved governance of the National E-Health Program - including the establishment of a broadly representative Australian Commission for Electronic Health (ACeH) which reports direct to Health Ministers.
2. Dissolution / Absorption of NEHTA into ACeH.
3. Transition of the PCEHR from an ‘Opt-in’ to and ‘Opt-out’ system with every citizen having a record created and populated for them unless the citizen takes active steps to ‘opt-out’.
4. Rename the PCEHR to the MyHR (My Health Record).
5. The undertaking of a range of reviews to eliminate duplication of activities between the ACeH and the Department of Health.
6. Privatisation of a range of current NEHTA / Department of Human Services activities.
7. Reviews of a range of e-Health infrastructure programs to ensure they are working as intended.
8. Improved measurement, reporting and transparency on all aspect of e-Health.
9. A range of steps to attempt to enhance clinical usability and utility of the system.
10. A range of miscellaneous smaller initiatives.
Sadly the review did not drill down sufficiently to ask the really important questions around the purpose and value of the PCEHR and whether the present design and implementation of the system was optimal or needed change. The assumption seems to be that be basics were all correct - a contention with which I disagree strongly.
It needs to be noted that the PCEHR Review was a report to Government and as such was not binding on Government.
Third there was the surprise announcement that former President of the AMA and one of three members of the PCEHR Review Panel, Dr Stephen Hambleton, had been appointed to be chairman of the NEHTA Board. There was a universal view that this appointment was a ‘good thing’, however one is forced to wonder just what impact and control the good doctor is likely to be able to exert on a Board and Organisation he recommend be ‘dissolved’.
At the time of the publication of the PCEHR Review it was announced that there was to be consultation with a range of stakeholders on the Review recommendation to assist the Minister to work out what to do next. This review consultation process began in late July, 2014 and is intended to last just six weeks until September 1, 2014. There is also to be an on-line survey which will be found at
The consultation process is being very tightly constrained and apparently when complete and considered to Government will decide what it will do regarding all the recommendations of the Review and move forward to implement its decisions.
It is hard not to reach the conclusion that the Government is struggling to work out just what exactly is should do. It is already clear that some of the recommendations are not possible in the Review recommended timeframes and that budgetary constraints will put a limit on what will be spent to ‘fix’ all the issues identified.
There is also a considerable body of expert opinion that suggests that a fundamental review of future options beyond what is contained in the very should Royle review should be undertaken, especially given the international experience of similar systems which suggests that the present national approach being adopted my not be ideal.
No matter what the consultation process throws up one gets the sense the very short consultation period may go some way towards preventing the best possible outcomes being reached. That said I suspect that by early next year it will be clear where the Government is heading. It is also possible that what is finally decided may be quite radical - such as outsourcing / privatising the entire initiative in order to let this very complex cup be ‘passed’ from Government. It is hard to argue the last 15 years has shown either side of politics as being very good at this sort of technology adventure.
Whether the course the Government is the right one we will just have to wait and see!
Comments welcome!


Bernard Robertson-Dunn said...


IMHO, the reason for the miserable lack of progress is because it's been seen as a "technology adventure".

When it comes to managing health information it should not been seen as a technology anything. Health IT is fantastic for diagnosis and detection - it creates meaningful data.

However, when it comes to health information, that's a whole different ball game.

It should be a matter of what information is needed to make better health decisions.

Creating data is very different from making decisions based upon that data. Unfortunately, too few people understand the difference.

Anonymous said...

So having strategies for e-Health per se is wrong? It presumes the answer is some form of technology, and the measure of success is its uptake.
Turning it around, DOH's EHealth Division might be renamed - 'Enabling Improved Health' Division. The objectives and measures of success might then be improving health outcomes,rather than how many people have registered for eHealth initiatives.

Terry Hannan said...

Bernard, your comments are right on the ball. As has been stated elsewhere.
"The critical functionality of health information management
in patient care is now a part of the WHO charter,
and as the WHO acknowledges that health, information
and management are critically interlinked when it states
that ‘there is no health without management, and there
is no management without information’."

Grahame Grieve said...

Bernard and Terry, I think you're being too tough.

There's a mexican stand-off here: there's no point re-engineering the systems because the tools don't exist to allow it. And there's no point creating the tools because the systems won't use them.

Which can you break first, if you want to fix that? So a bunch of stuff has been done at the tooling level (all countries have tried variations on the theme), but they've all failed to deliver because the business re-engineering hasn't happened.

While we can legitimately be concerned about the solutions/outcomes used as part of the tooling, there's clearly been progress, and that is also ongoing. Now, I predict, attention will move the way you envision.

(see my quote here:

"Over the next few years the focus will shift from data interoperability to clinical interoperability")

Dr Ian Colclough said...

Perhaps I have misunderstood what Graham is saying:
1. the tools don’t exist to allow systems to be re-engineered, and
2. there is no point in creating the tools because the systems wouldn’t use them.

On the surface Point 2 seems like a self defeating observation. For example, if the tools did exist surely systems could be ‘re-engineered’, that is, re-designed and re-architected. However, if Graham means it is not practicable or feasible to develop and use new tools to re-engineer existing systems then I can understand and accept that position because the mix of outmoded design thinking and legacy technology make it virtually impossible to bring a new generation system to market built upon outmoded legacy foundations and solution design.

In other words, in the context of the life cycle of system development – there is a point in time when the system needs to be totally replaced with a new system underpinned by new design, new ways of thinking and new approaches to solving the problem with new concepts and new technology. From a commercial and business viability perspective that is a very complex problem. Taking an old system and using new tools (if they did exist) to convert to a new system is fraught with a minefield of problems best avoided.

This suggests to me that there is a place for supporting and nurturing new boys on the block with new approaches and new thinking to problem solving utilising reasonably new, yet stable and mature, tools.

Most likely the old system will be mature and fairly stable and have a level of functionality that works; albeit with limitations which one must be prepared to accept as a compromise position. Very rarely will the company, which has built its business around its original system, be able or be prepared to re-architect, design, develop and test a whole new generation of functionality embracing a different approach and a different way of thinking to that employed previously.

On those occasions when that is attempted the company usually employs the original design thinkers to approach the problem with a different way of thinking. Therein lies the rub.
Unfortunately their pre-wired and pre-conditioned minds and personalities prevent them from embracing a whole new way of thinking as does the old environment and the organisation’s culture in which they work, compounded by the constant commercial imperatives to keep growing the business at the same time.

In short, good and competent people though they may well be cannot, rather than will not, change, so they cannot come up with that elusive new approach.

Some may wish to comment further – but it is as Bernard is oft want to say “a very wicked problem”.

To my mind this is why Australia urgently needs to seriously invest in technology start-ups and not continue letting the opportunity pass while waiting for others from overseas to tell us how we in Australia should do it their way.

Grahame Grieve said...

Ian, it's really a system-of-systems problem. No single system can solve the problems, unless some start up decided to boil the ocean and build one solution for everyone.

As long as it's a system-of-systems problems, there's a need to innovation across the board - exchange standards and culture, terminology, liability rules, policy and regulations, and most of all, the desire to make a difference to the clinical process.

Judging when to jettison an existing approach and start again is a very difficult thing; recent IT history is full of examples of companies that died because they didn't do it when they should, or they did it when they shouldn't.

So it seems to me that the general problem calls for a range of innovations, some that are conservative and some that take risks.

I've been working hard on innovation in the data exchange space, and we're getting a little traction with that at the moment. But many other things are required to make real change.

Anonymous said...

Graham perfectly encapsulates the eHealth conundrum when he says – “As long as it's a system-of-systems problems, there's a need to (for) innovation across the board - exchange standards and culture, terminology, liability rules, policy and regulations, and most of all, the desire to make a difference to the clinical process.

In doing so Graham and Ian are in synch – a range of innovations are required.

The costly tragedy for Australia however is that Australia’s eHealth innovators are not being supported - the obstacles they face in accessing critical long term patient investment funds are enormous.

Add to this the inbred, shortsighted, risk averse, culture of the bureaucrats and their political masters, with their overriding preference to embrace established legacy systems that are so cumbersome and inflexible by today’s standards, and the huge challenges faced by innovative start-ups when establishing themselves in the Australian market will be obvious.