Tuesday, January 13, 2015

A Belated Welcome To 2015. I Wonder How It Will Play Out In E-Health? I Am Not All That Confident For Now.

Over the holiday break I was challenged to suggest what might be needed to make a positive difference in e-Health.
What I suggested then were that five actions were needed. These were:
“Action One:
Recognise that there are two distinct clients for e-Health systems and services and that their needs are not by any means the same - meaning that different systems are required for each. The professional clients (doctors, nurses, allied health etc.) need systems that enhance their clinical capabilities, improve record keeping and facilitate their secure sharing of clinical information to improve patient care and safety.
The consumers need systems to allow them to record their own information while at the same time having access  to, ideally, the live clinical systems so they can better engage with and understand and contribute to their care.
It is obvious the present PCEHR does neither of these things well.
Action Two:
We need to recognise we don’t need a single monolithic System but that we need an e-Health ecosystem where health information flows efficiently, accurately, securely and privately between appropriately credentialed actors within the health system and to and from consumers.
Action Three:
We need an updated National E-Health Strategy that consults all stakeholders properly and provides the  governance, leadership, strategic technical, standards and managerial pathways to actually achieve the goals cited by the CHF for this domain. We then need the Strategy properly funded and led - as did not happen with the 2008 version.
Action Four:
Before anything more is done or spent actually undertake a proper in depth peer-reviewed evaluation of what e-Health in all its guises has achieved in Australia and what has been achieved in the rest of the world that might be applicable to Australia. This research should inform what comes next.
Action Five:
We need to understand that no-where in the world has a transition to e-Health been easy, uncomplicated, pain free or without missteps. As we increasingly realise, getting this right is a very considerable and some might suggest near impossible challenge that takes lots of time, lots of money and dedication - as well as quality leadership and governance for success. E-Health is not something for generalist bureaucrats and technicians to have repeated goes at and repeatedly fail at!”
Most who commented rather liked what I had suggested but still seemed rather pessimistic about the next decade or so. I think, on reflection, that what I missed in my post was that these five actions need to be seen as an integrated package. All five areas need to be properly, openly and transparently addressed. You, for instance, can’t develop a quality strategy and then not fund it - as happened in 2008 - and you can’t change management without making sure they have a clear strategy, commitment and real funding.
There is no doubt that 2015 will be a pretty interesting year with a new Federal Health Minister who has the PCEHR ‘hot potato’ placed right in the middle of her desk and who lacks any apparent expertise, right now, in the Health or E-Health sector. Deciding what to do with the PCEHR is going to be one of the most difficult parts of the portfolio, if we ignore the extreme difficulty of sorting out what to happen with the Plan B Medicare Co-payment - now that the AMA and the RACGP are now running public campaigns against the plan.
To me if the PCEHR is a ‘hot potato’, the co-payment is a grenade with the pin removed!
The old curse of ‘May You Live In Interesting Times’ is more that apposite and the times may indeed turn out to be more than challenging!
David.

10 comments:

Terry Hannan said...

David,
Action Two: you have defined a strong argument for Open Source systems. Samples cited below and reasons for supporting this approach.(1-3)
Action Three: I could not agree more.
Action Four: the failure to undertake this approach has been a major stumbling block to any significant progress in Australian eHealth. See full issues of the International Journal of Medical Informatics in 1999! (4)
Your final discussion point that focusses upon “a new Federal Health Minister who has the PCEHR ‘hot potato’ placed right in the middle of her desk and who lacks any apparent expertise, right now, in the Health or E-Health sector” is one that may delay and impair any effective eHealth implementations for more than a decade into the future. Despite the accolades for Peter Dutton he really did not know what eHealth was all about (some of us who have been doing it for 30 + years still struggle) so how is our new Minister going to be advised by the health bureaucrats.
1. Mamlin BW, Biondich PG, Wolfe BA, Fraser H, Jazayeri D, Allen C, et al. Cooking up an open source EMR for developing countries: OpenMRS - a recipe for successful collaboration. AMIA Annu Symp Proc. 2006:529-33. Epub 2007/01/24.
2. Seebregts CJ, Mamlin BW, Biondich PG, Fraser HS, Wolfe BA, Jazayeri D, et al. Human Factors for Capacity Building. Lessons learned from the OpenMRS Implementers Network. Yearb Med Inform.13-20. Epub 2010/10/13.
3. Wolfe BA, Mamlin BW, Biondich PG, Fraser HS, Jazayeri D, Allen C, et al. The OpenMRS system: collaborating toward an open source EMR for developing countries. AMIA Annu Symp Proc. 2006:1146. Epub 2007/01/24.
4. Safran C. Editorial. Int J Med Inform. 1999;54:155-6.


WELCOME BACK TO 2015!

Hemal Ruparelia said...

Great post! Especially about the need to view and better segment the users of the system into clinicians and patients (they have already done this, but like you say, not well). Agree with those action steps. Not convinced that they will actually be taken, unfortunately.

To add to Terr'y comment - open source would be fantastic. I read recently that about 97% of the internet is powered via open-source code (the open source Apache Web Server beating out the mighty Microsoft in years past having a role in all this). The community input on an open-source platform would be immense - Australia would end up with an eHealth system far cheaper and more useful.

Sadly, it is a move I don't see the government making ('what if somebody uses the opensource code to breach security?' ).

With that in mind I think the future of eHealth is likely going to come from the private sector.

Anonymous said...

Terry Hannan has overlooked the obvious when he says ----- "a new Federal Health Minister who has the PCEHR ‘hot potato’ placed right in the middle of her desk and who lacks any apparent expertise, right now, in the Health or E-Health sector” is one that may delay and impair any effective eHealth implementations for more than a decade into the future."

Not so Terry I fear.

The fact the new Health Minister lacks expertise (as you say) is precisely why you will see Telstra being able to exploit the Minister's vulnerabilities and develop a deep, wide, ubiquitous position over a vast part of the market with the Government's and the Minister's support starting with the thin edge of the wedge - The Department of Human Services Call Centre pilot project.

Anonymous said...

As someone who has dedicated a large chunk of his life to contributing and cultivating open source projects, you are not going to be able to rely on a community of volunteers to build the system we need. Any decent open source project has had or will require a significant chunk of money to fund it. This isn't necessarily just throwing money at it, but in hiring a team of developers to nurture it and contribute their work back to the main community, as well as support and maintenance costs. In this particular case I would be concerned with using an open source product for health information. Whilst the Internet is powered by mostly open source components, you are talking about web servers, security, sites and browsers - not applications and major pieces of infrastructure like eHealth systems.

Bernard Robertson-Dunn said...

re: "Whilst the Internet is powered by mostly open source components, you are talking about web servers, security, sites and browsers - not applications and major pieces of infrastructure like eHealth systems"

I agree totally.

IMHO, open source is fine for technology infrastructure, but not for medical information systems.

How many open source banking systems are there? None that I know of, and bank transactions are nowhere near as complex as medical/clinical information systems.

Grahame Grieve said...

hi Bernard

"IMHO, open source is fine for technology infrastructure, but not for medical information systems"

You're both right and wrong. I see it differently - open source works really well for plumbing, for platforms. It doesn't work well for writing solutions in applications.

Medical Information systems typically have a leg in both comps, but to different degrees, depending on what the do. So some solutions will benefit more from open source than others.

However it's not true that medical information systems can't be entirely open source. openMRS is an entirely open source project that is a real -and widely used - medical information system. It does have real money behind it (grants from foundations etc). And it is the worst system on the market - but that's because you can't undercut it for price; be better, or die. Open source systems are always the worst on the market ;-)

Justine Raczkowski said...

Thanks for the post. I'm also concerned that we're not adequately equipping customers with the tools to use e-health, in particular seniors. As predominant users of healthcare, are their needs being adequately addressed?

Justine Raczkowski

Anonymous said...

@Grahame Grieve

"Open source systems are always the worst on the market" ";-)"

I dearly hope your emoticon illustrates the extent of your jest?

If not, I struggle to understand that which is greater, your ignorance or prejudice of open source software...

I dearly hope for yours and ehealth's sake your incendiary statement is pure, unadulterated jest!

Grahame Grieve said...

"If not, I struggle to understand that which is greater, your ignorance or prejudice of open source software..."

It's not a jest. But i'm not ignorant or prejudiced against open source software. In fact, I spend nearly 100% of my time using or writing it, and I lead several different open source projects, some of which are well known in healthcare IT circles.

I first heard that open source is the worst option on the market from Seth Godin (at an open source conference, no less).

The logic is actually simple: a product occupies a price point - a set of benefits for an amount of cost. If the product offers less benefits than a cheaper alternative, it will go out of existence, since who would buy that?

And since OSS is free then you can't under cut it for price, and so either you exceed it for benefits, or you go out of business. Ergo, open source software is the worst software available. Put more positively, open source sets the floor of the market - you have to outperform it. In many sectors, though, the floor gets higher and higher to the point that it's also the best, and commercial software can no longer compete, and open source is all there is left.

The ;-) is because all this is a gross generalization. A generally awful software package can continue to dominate the market for a variety of reasons (whether open or not), so the real world is (as usual) more complex than our theoretical models

Anonymous said...

@Grahame

I believe you can see the faulty logic in your own reasoning underlying your fallacious statement, and you won't have to look or think to hard to find it.

On a more practical front, viewing objective stats on Web Server software market share penetration demonstrates a more concrete example of the error in your logical ways:

http://w3techs.com/technologies/overview/web_server/all

;-)