Friday, May 22, 2015

An Expert View Of Just How Off The Rails E-Health Seems To Be At Present And How It Might Be Fixed.

This appeared last week in response to the E-Health Announcements last week and seemed to me to put a sound view of what we are seeing and to be trying to suggest the level of thought being applied to e-Health globally my need to be improved. More people need to read it!

A modest e-health proposal to government

Enrico Coiera
May 12, 2015
Dear [insert country name] Government,
E-health is hard. I think we can all agree on that by now. You have spent [insert currency] [insert number] billion on e-health programs of one form or another over the last decade, and no one knows better than you how hard it is to demonstrate that you are making a difference to the quality, safety or efficiency of health care.
You also know that so much of e-health needs to happen in the public domain that, irrespective of your desire to privatise the problem, you will end up holding the can for much of what happens. E-health is your responsibility, and your citizens will, rightly or wrongly, hold you accountable.
It is so hard to get good strategic advice on e-health. You recently commissioned [insert large international consultancy firm] to prepare a new national e-health strategy, and it didn’t come cheap at [insert currency] [insert number] million. In the end it told you nothing you didn’t really already know, but at least you can say you tried.
You also commissioned [insert large international consultancy firm] to prepare a business case to back up that strategy, and it didn’t come cheaply either at [insert currency] [insert number] million. The numbers they came up with were big enough to convince Treasury to fund the national strategy, but deep in your heart of hearts you know you’ll never see a fraction of the [insert currency] promised.
It’s also really hard to find organisations that can deliver nation-scale e-health to time, to budget and of a quality that the professions and the voters all agree it’s a good thing. You want the IT folks who build these systems to understand health care, its needs and challenges, deeply. Just because they can build a great payroll system or website does not qualify them to jump in and manage an e-health project. Do you remember how [insert large IT company] ended up crashing and burning when they took on the [insert now legendary e-health project disaster]? We can all agree that didn’t go as planned, and that you didn’t exactly enjoy the coverage in the press and social media.
What you really want firstly is impartial, cheap and informed expert advice because you are in the end driven to do the right thing. Given the heated and partisan nature of politics, that advice needs to come from safe and trusted individuals. That often means the advice comes from within the tent of government, or from paid consultancies where legal contracts and the promise of future work secure your trust. You also want the IT folks who build your systems to be deeply trained in the complexities of implementing systems for e-health. The health professions, and indeed the voters, also need to be sophisticated enough to understand how to use these systems, and their limitations. That’s going to maximise your chances of success, as well as blunt the uninformed chatter that so often derails otherwise good policy.
Our proposal is a simple one. We suggest you set aside 10% of the E-health budget to train the next generation of e-health designers, builders, and users. Use the funds to resource training programs at the Masters level for future e-health policy leaders, as well as system designers, builders and implementers. Let us provide incentives to include e-health in health profession training both at primary degree and for continuing education. Let us also invest in training the public in the safe and effective use of e-health. Investing in creating a critical mass of skilled people over 5 years will be your best insurance that, when you are again faced with e-health, you have a real chance of doing the right thing.
Given how little outcome you have had for your e-health investments over the last decade, and the harsh reality that little will change over the next, this is a chance to rewrite the script. Invest in people and skills, and you might find that with time e-health isn’t so hard after all.
[insert name of concerned citizen, NGO, or professional association]
[insert date]
Here is the link:
I like the idea - but we need to pause the spending and doing things until we get these experts in place!


Dr Ian Colclough said...

I absolutely concur with the sentiments expressed with the exception of the 2nd last paragraph.

As a proposal the 2nd last para has merit for the long term.

However to address the real problems today a whole new way of thinking is required now and that means we need to identify the 'right' people and secure access to them to develop a pragmatic, realistic, achievable and affordable way forward using a very small amount of the $485 million earmarked in the budget; whilst quarantining any further expenditure of the $485M until this first stage has been satisfactorily completed.

Most of the people I would use to do that job have not been involved with NEHTA or even the Department.

Andrew McIntyre said...

The traditional way of advancing eHealth has been to allow innovation and once it appears to use a standards process to capture the best ideas and make them available to all players and create a level playing field and ensure safety and interoperability.

Despite the ignorant naysayers HL7V2 has been very successful using this model and progress in the nineties and early part of this century was impressive. We have had pathology and radiology result distribution working for nearly 20 years and despite the warts its still working.

We have gone off the rails when governments created pots of gold which have attracted the professional government fund consuming consultancies. They have been very successful at consuming every drop of taxpayers money with a chorus of "We need more funding" sung in tune by all of them.

Rather than standards built on successful models, argued by the technical people who have intimate knowledge of the issues we have high paid consultants, often with very little real world experience at the coalface. These people always want to create something new, expensive and using whatever technology that is trendy and buzz word compliant. The xml cheerleaders led HL7 up the "xml and modelling will fix everything" pathway that led to the failure that was HL7V3 (and CDA).

Vendors would want the cheapest solution that build on existing codebases and was evolutionary rather than revolutionary. The area is so complex that producing something new that that is better is very hard. It will fix the obvious errors that have been apparent while making new mistakes that the existing standards did not have. Government continually wants to bring in someone new to solve "it" and those white knights soon find out that its harder than it looks, but in the process billions of dollars are wasted.

The best solution in Australia would be to stop refilling the pot of gold and reinstate a consensus, volunteer standards process with a government commitment to enforce compliance ie provide governance. Spending some money of education of people in the field of eHealth is good, but its much better to get competent IT trained professions working of complying with standards, as they will learn quickly in that environment. Government funded standards development does not work. Governments need to ensure that software is standards compliant and the players in that market will then volunteer to develop and enhance standards as its in their own interest. Technical people with real issues and knowledge will then attend the meetings rather than well dressed, smooth talking buzz word educated representatives of professional pot stealing companies. The government has been, and is being professionally played. This is true internationally.