Sunday, January 22, 2017

Draft Strategy Submission for Comment - 22 January, 2017

National Digital Health Strategy - Submission - DG More - January 2017

Introduction

The following submission has been prepared to offer some commentary and input to the Strategy process, now underway, and to assist in the ongoing development of the National Digital Health Strategy.
With experience of over a decade of preparing such submissions I have to say the submission is provided in hope rather than based on past experience of making any difference!

Author Of Document

This document is authored by Dr David G More MBBS BSc(Med) PhD FANZCA FCICM FACHI.
I have had over 20 years involvement, in one form or another, in the area of Health Information Technology (e-Health) and been a contributor to many projects in the area including a role in the development of the 2008 National E-Health Strategy and discussions on the 2014 Update.
I am reasonably well known in Health IT circles as the author of a blog on Health IT (www.aushealthit.blogspot.com) which has now been in operation continuously since 2006 and I have been widely quoted in the professional clinical press, the national press and in reports published by the Parliamentary Library.
I have no direct financial interests in any entities involved in Australian Health IT and receive no payments from the work I undertake with respect to the blog.
Over the last 4-5 years I have made submissions in the Health IT domain when requests for such submissions have been made by Government and these are available on the DoH website (www.health.gov.au).

Purpose Of This Document

I wish to provide comments on three aspects of the current consultation.
First I wish to point out that the process is deeply flawed for a number of reasons. Among these are:
1. There has not been an appropriate detailed knowledge base provided to those being consulted to permit informed decision making. At the very least those consulted should have been provided with:
a. A comprehensive review of what is happening in the Digital Health Domain overseas with a review of what has been shown to make a positive difference in terms of either cost, quality, safety or patient satisfaction.
b. A comprehensive review of the current status of the Digital Health Domain in Australia and what has been shown to work (or not) in Australia.
c. A review of the current Digital Health Capabilities and Workforce with deficiencies clearly identified.
d. An economic review of expenditure at a State and Federal level on Digital Health over the last decade and the benefits received for that expenditure.
2. An implicit assumption that seems to be built into virtually all documentation that Digital Health is ‘good’ and we just need to improve to make all right. I conducted a poll on this assumption a little while ago and the outcome was interesting.
AusHealthIT Poll Number 352  – Results – 16th January, 2017.
Here are the results of the poll.

Is The ADHA Correct In Assuming That 'National Digital Health' Is A 'Good Thing' And All We Need To Do Is Work Out How To Do It Correctly And Get On With It?

Yes 21% (22)
No 58% (62)
ADHA Does Not Assume Digital Health Is A Good Thing 0% (0)
I Have No Idea 21% (22)
Total votes: 106
 3. Despite the enormous cost and almost non-existent clinical utilisation of the myHR, there appears to be an implicit assumption that this program is vital and central the Health Care Service Delivery (which it is clearly not).
In summary, the consultation is being conducted based on a combination of relative ignorance, feel good assertions and an absence of evidence of real impact or utility.
Second I believe there is no credible plan being put forward by ADHA and the bureaucracy as to just what needs to be done to move from the present myHR dominated environment to a future state that addresses the real needs of patients and clinicians as a priority, rather than serving the bureaucratic needs to gather detailed personal health information in a centralised database for purposes that are barely disclosed.
As I commented very recently on the call for input:
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In that vein it the second paragraph that stands out.
“ (Quoting ADHA) There’s nothing more important than our health and the health of those we care about. Putting data and technology safely to work for patients, consumers and the healthcare professionals who look after them can help Australians live healthier, happier and more productive lives.”
I am sure all who read here will be well aware of the risk of making ‘sweeping generalisations’, and that somehow glossing over detail a false impression can be created. When this impression leads to government expenditure on a grand scale then we all have a problem.
So stepping back, obviously, appropriately used data and information is crucial for the proper operation of the health system in most aspects from research to patient care etc. Think everything from research management systems to patient management and scheduling systems. Trying to do without these systems would clearly be a waste of time and money – if not impossible – think the management of major clinical trials to the optimisation of patient flow in a major hospital – all basic stuff that, if it did not work, no one would pay for and use it!
Equally there are a zillion technologies that are vital from MRI Scanners and drug discovery to the various monitoring systems that track our patient’s progress. The evidence that these technologies do / have make a positive difference is well documented.
But the ADHA is not interested, as far as I know, with all this. Their interest is in patient specific information and how it is shared and communicated by digital systems and this is where we hit a problem with evidence as well as all the other issues of safety, privacy and so on.
There is no doubt that a well-designed GP System can improve the quality and safety of what the GP does with and individual patient and make it easier to follow a patient’s clinical journey and treatment. There is good evidence to this as well as much evidence that current systems are by no means perfect and still need more work.
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Equally there is decent evidence supporting the deployment of clinical systems in Hospitals and specialist and allied health practices and well as linking them with information providing systems (pathology, radiology etc.).
Where evidence is lacking and history is littered with failures are large national, all things to all men (and women) health system initiatives that centralise information at national scale.
Third, and rather bringing the above two threads together there was a valuable contribution from ACHI to the earlier call for input – in April 2016. I quote a recent blog:
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In response to a draft National Digital Health Strategy made available in April, 2016 ACHI produced some excellent suggestion that are well worth discussion.
This was in the form of some specific and actionable recommendations to Government. These were:
“Recommendation 1: That the strategy reference and benchmark Australian activity with international comparisons.
Recommendation 2: That the strategy properly outline existing activity and lessons learned from outputs from the 2008 strategy and other initiatives.
Recommendation 3: That the strategy outline clearly and unambiguously the problems that it is trying to solve, with specific objectives and indicators for success.
Recommendation 4: That the strategy be properly supported by an evidenced business case for its recommendations.
Recommendation 5: That the strategy outline an informative and comprehensive approach to clinical governance, data and information governance, quality and safety.
Recommendation 6: That the strategy define an approach to development of a strong and highly competent informatics workforce.”
Just wandering around asking people what they want and what their aspirations are is really not the way. What is needed is a defined process of research, information gathering from the front line and a hard-nosed look at what works, what is safe, what is reasonable and what has measurable benefits.
The issue is to then define an idea ‘future state’ and work out how to get there from here!
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Recommendation.

Overall I believe the consultation process to date has been the ‘soft / easy’ part! What is needed now is the ‘hard’ rigour of an evidence based planning process, conducted by real experts, that wins broad patient and clinician acceptance. My take is that ADHA is not even 1/3 of the way there so far and needs to seriously expand the scope, range and depth of what they are doing, if anything useful is going to be delivered. Overall much more detailed evidence-based work and consultation is needed if the whole effort is not to be both flawed and wasted.
Note: I believe this view is confirmed by the recent summary of the findings to date in the Strategy Process which was  published last week:
A Final Crucial Point.
A last and crucial comment is to point out that the Australian Health System is, at an extreme simplification, a public hospital system run by the States and a private clinical delivery system which operates to a large extent separately from Government – except to charge what it chooses – for the services provided. Clinical services are actually delivered – outside Public Hospitals – by a large number of private (usually) small businesses.
A core issue for the Strategy development process is therefore to work out just where a Commonwealth National Digital Health Entity actually fits and just what it should be doing – and more importantly what it should NOT be doing. Sorting this out will be fundamental to the success of any proposed Strategy. At present the raison d'ĂȘtre of the ADHA is not at all clear.
In summary, we need to know just where ADHA fits and just what it should be doing with the enormous resources it seems to have available to actually deliver health improvement for the Australian population, at a level beyond the feel-good motherhood statements so typically trotted out.
22/01/2017

1 comment:

john scott said...

David, an excellent submission summarizing an extensive and complex conversation across a range of diverse but united interests, united in their desire to see a better system delivering better outcomes for all stakeholders.

In terms of a compelling narrative it takes me back to my own origins in this now ehealth/digital health environment.

In the late 1980's I was given evidence from the Telecom Research Labs that nurses were spending 67% of their time dealing with information; either chasing it or chasing someone to give it to. This evidence served as the basis for a national initiative called "Moving Information to Care" after the title of the Federal Government's submission to Australian Health Ministers.

In contrast to the past two decades of work, we started with a simple proposition: What would it look like if the 'system' were working the way you wanted it to in order to improve the flow of information to the point of care? This question invited contributions and laid the ground for effective cooperation and collaboration.

The rest was really working very closely and in a trustworthy fashion with the full (public and private) health system to work that out. We learned a lot and demonstrated how you could solve many of the current challenges.

It is possible to point to health communication services that operate today that were the product of these efforts. And, the kicker is we only spent about $7 million over five years.

So, my additional question is: What relevance does this original effort and its findings have for the current strategy process?